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Environmental Health Department <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 />SANJUAQUIN <br />- COUNTY— <br />Greatness grows here <br /> Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />^Vehicle wash <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 />knowledge, and meets the California Health & Safety Code requirements. If the food facility <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 />I 1. To be completed by APPLICANT <br />Business Name. C0P£EI\S iWMUpiAt* #_ <br />Owner/Operator Name 0 S C-K |2, N/'Vft' [\l I) 6 L CD A <br />Business Mailing Address I I 3 H 2 YV C 1.0 I? 2. ________ <br />City TTfiCM State Zip ^l53/feus. Ph <br />i, OSCkZ CDpg-Irrk. 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 pepatjeft-j <br />Signature Date ^7 / 2.02^ <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name U N' /) K/ IIVT)2V CY- ________________________ <br />Address nn s- union rr Bus. Phone <br />City S TD C/^Ti N L^Owner/Ooerator <br />Check all appropriate services provided: <br />Wastewater disposal <br />E^Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. y fr/ZA- <br />correct to tne bes^eiijTv kn< ‘ ' <br />operator fails to\om^wrtfo the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owper^allnottfy the EHD immediately. <br /> <br />Signature Date I 7^ / <br />3. To b^Zompleted 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.