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Environmental Health Department <br />/s? Zt-'l Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Date <br />REHS Signature Date <br />Complete sections 1 and 2. If your commissary is located cutside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br /> Lie. Plate# Cc'ZGC\Z <br />! z.c\_______ <br />vZElectrical hook-ups <br />^/Toilet and handwashing <br />°otable water <br />^Vehicle wash <br />(S^Llo <br />_________Bus. Phone, <br />Owner/Operator <br />' SAN JOAQUIN <br />COUR"Y <br />1868 E. Hazelton Avenue [ Stockton, California 952051 ? 209 468-3420 | F 209 464-0138 i v/ww.sjgov.org/ehd <br />2^001 W <br />3/(0/ Y(Y, <br />2oq-3>64-hS£) <br />3 <br />FA# <br />M ^<YTj I J-P ? <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />2-^3 <br />Business Name t&cfiS__________________ <br />Owner/Operator Name fV'YAor-i < to AA - £<A0\ooZ<:, <br />Business Mailing Address xSiY QCAtrcA <br />City, Lcd^State CA Zip Bus. Ph. 2OK nA A- F\S5Alt. Ph. ('2C2 } <br />iZ-.lvyG , 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 <br />Commissary Name CqyVXyu SSQjAj <br />Address “PMB <br />City Uy\j Zip ^5240 <br />Check all appropriate services provided: <br />v/S-compartment sink <br />Food preparation <br />Store refrigerated food <br />\Zbvernight parking <br />____, hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />y/Wastewater disposal <br />^z^olid waste disposal <br />'^Hoi & Cold water for cleaning <br />Store dry food/supplies <br />i. fttoMo <br />» t r t I t r I ’ t • <br />operator fails to comply with the conditions, of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner sh^Ibngtiiy t^e EI^D^ppiediately. <br />Signature Date 3^ <br />3. To 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.