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< <br />Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name Lie. Plate# <br />?Zg ADate <br />Owner/Operator <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 />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <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 />p Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />SAN JOAQUIN <br />-COUNTY — <br />Greatness grows here. <br />Dat^^ / 2c <br />P Wastewater disposal <br />[Jj Solid waste disposal <br />p Hot & Cold water for cleaning <br />0 Store dry food/supplies <br />I, /V) ______ <br />1. To be completed by APPLICANT_____ <br />g/ <br />Owner/Operator Name (A <br />Business Mailing Address ToS <br />City StateZip / Bus. Ph. 2<A <7 Alt. Ph. <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 discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and pej <br />Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR___________ <br />CommissaryName A pa# <br />Address £ //. /J- c'Bus. Phone <br />City Cc Zip A / 4 Owner/Operator <br />Check all appropriate services provided: <br />0 3-compartment sink <br />T5 Food preparation <br />LT Store refrigerated food <br />P 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 />S i g n at u re_^___________________