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Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />Lie. Plate # <br />Date <br />Date <br />Date REHS Signature. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />------COUNTY------- <br />Greotness grows here. <br />cajsT' <br />Business Name xOj^\ <br />Owner/Operator Name V-\j\S S <br />Business Mailing Address <br />City State Zip 5TA 7^ Bus. Alt. Ph. <br />I, V*AS , 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 />Signatu re Date <br />______________FA#_____________________ <br />Bus. Phone Q.cT~ X <br />^□FEIectrical hook-ups <br />^QToilet and handwashing <br /> Potable water <br /> Vehicle wash 2 o <br />o rr _________________________ , hereby state that the information I have provided is current, true e^I <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food faci^ <br />rri <br />'g-Wastewater disposal <br /> Solid waste disposal <br />P Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, ___________ <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, <br />commissary owner shall notify the EHD immediately. O <br />Signature Date_H/ ----------------------------------- <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. <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address <br />City Zip Owner/Operator <br />Check all appropriate services provided: <br />f13T3-cornpartment sink <br /> Food preparation <br /> Store refrigerated food <br />^Overnight parking <br />cn 2 <br />H W 0 <br />2 On- <br />zj • 02 s o <br />o zi m <br />2