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Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date <br />'ISU- SC/IU> <br />5 /rcjUe. <br />Date <br />REHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | 1 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd 5 <br />— <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />3. To be <br />I, <br /> Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br /><~^z\LZr 11' \ i z , neieuy didic uiai uie niiuiiiiauuii i iiave piuvicieu is current, true and <br />□rrect to the besl of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />B SAhhJOAOUIN <br /> ------COUNTY------ <br />Gr^otness ^rotvs here. <br />1. To be completed by APPLICANT <br />Business Name. _Lic. Plate # <br />Qwner/Operator Name A B A V Tl ^S TA P A <br />Business Mailing Address Hl P I N H I L L R- <br />City ^ rbfX^NfctateCK Zip P^Oteus. Pt/.ID^Ph. <br />1. , 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 />2. To be completed by COMMISSARY QWNER/OPERATOR <br />Commissary Name M10 N j^~/ p~- <br />Addresstl 11 S'- UNION ST~ __Bus. Phone_ f _______ <br />City Zip Owner/Operator S/^/V'J'] <br />Check all appropriate services provided: <br />Wastewater disposal 3-compartment sink <br />Solid waste disposal Food preparation <br />Hot & Cold water for cleaning Store refrigerated food <br /> Stare dry food/supplies^ O Overnight parking <br />i. frejJQ- "TiUoefo hereby state that the information I have provided is current, true and <br />correct t< <br />operator failsjrxxomply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissar/owiQr shalLnotify^i^^HD immediately. <br />Signature Date ^V/26 /2Z)?U> <br />ipleted 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.