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Environmental Health Department <br />Date 'V\ <br /> <br /> PER/ <br />V-2 - ZGDate <br /> <br /> rv. I <br />Date REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 | www.sjgov.org/ehd <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 /> Electrical hook-ups <br /> Toilet and handwashing <br />Potable water <br /> Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility $ Caterer <br />SAN JOAQUIN <br />------COUNTY------- <br />itinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />Hi <br />Commissary Name Lob ( <br />Address Z- <br />L-O b' / <br />MBS <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Overnight 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 />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 <br />__________FA#_____________________ <br />Bus. Phone 2.^- JO <br />City I—O £> I Zip c[5 2-V O Owner/Operator ~ t/Z-B g^-<3~ <br />Check all appropriate services provided: <br />^Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br />O Store dry food/supplies <br />I, TUbP <br />Business Name .Mb <br />Owner /OperatorName <br />Business Mailing Address /Y\ ^2.1 <br /> StatcCA Zip y^Z/^-Bus. Ph.^&ft zW- Z^^AIt. Ph.^g^^^^- <br />I, , 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 discpfit <br />revocation and p^naltipY <br />Signature <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />f . <br />Lie. Plate#