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Environmental Health Department <br />Lie. Plate # L]\a/VH G51 <br />Alt. Ph. <br /> <br />Vehicle wash <br />Date <br />Date REHS Signature <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 1 F 209 464-0138 | www.sjgov.org/ehd <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> I A "T” 1 I I I I A \ 1 1 Z’S A A IT" ~ <br /> <br />■Electrical hook-ups <br />Tojjet and handwashing <br />Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />COUNTY <br />CommissaryNam e 7t <br />Address ESL Bus. Phone <br />City 'Zip Owner/Operator <br />Check^11 appropriate services provided: <br />(J/Wastewater disposal □x3-compartment sink <br />gp^olid waste disposal fi^ood preparation <br />CkHot & Cold water for cleaning (Q^Stpre refrigerated food <br />P^tore dry food/supplies pzOvernight parking <br />I,A yr-_____________, hereby state that the information I have provided is current, true and <br />correct teftne best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />Signature —Date ~ ~ (s' ____________ <br /> <br />3. Io be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. | <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. The above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />Business Name i, 1110 <br />Owner/OperatorName I Sqg(. JuatC-L__________________ <br />Business Mailing Address IQT?. 5 5^ <br />City LqA\State ip 9 52A|0 Bus. Ph. <br />I. \f)QUC •Juqi£'Z., hereby state that the above information is current, true and correct to <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. , <br />Signature^Date <br />FA#________________________