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Environmental Health Department <br />Date <br />REHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />tS^EIectrical hook-ups <br />Ek'foilet and handwashing <br />□^Potable water <br />□kVehicle wash <br />_FA# <br />_______________Lie. Plate# C/yPHs? <br />vela Z ________ <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />p. To be completed by APPLICANT ] <br />6 ( OQp <br />Greatness grows here. <br /> Bus. Ph.Alt. Ph. <br />, hereby state that the above information is current, true and correct to <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements, <br />commissary is discontinued, the perrpiLhob <br />revocation and penalties. <br />Sign a t u re__________________ <br />Business Name <br />Owner/Operator Name <br />Business Mailing Address <br />City State Zip. <br />I,______________ <br />Uie best^of my knowledge and agree to utilize my approved commissary in accordance with California <br />. If the use of the <br />must notify the EHD. Failure to notify this office may result in permit <br />__________________________Date <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR ~ <br />Commissary Name <br />Address_^^^TS~ ^4- Bus. Phone <br />City.—Zip Owner/Operator <br />Check all appropriate services provided: <br />[JK^Vastewater disposal Qr<^compartment sink <br />EK^olid waste disposal (0^Food preparation <br />^Idot & Cold water for cleaning (j^^tore refrigerated food <br />C^tore dry food/supplies ^Overnight parking <br />11-----------, 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 />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 -/"7 <br />Lgyro 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.