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Environmental Health Department <br />2^ <br />Date <br />OElectrical hook-ups <br />U^Toilet and handwashing <br />S^Potable water <br />S4IW0A0UIN <br />-----COUNTY------ <br />Greotness jrcws here. <br />1868 E. Hazelton Avenue) Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />____Lie. Plate # <br />Date O \ - \ Q - ________ <br /> <br />j. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in -- ------------------------------------------------County The above food facj|jty 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 />REHS Signature <br />K^S-compartment sink <br />S^ood preparation <br />CTstore refrigerated food <br />8"Oven light parking <br />cArmAtt u -----------------hereby state that the information I have provided is current true and <br />t°th|e best of m'' knowleSge, 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 ownerjsli^ll notify the EHD immediately. <br />Signature <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 />1. To be completed by APPLICANT ~ <br />Business Name Cr iertx <br /> Owner/Operator Name (bn<eA-Vfr GAvere.?. <br />Business Mailing Address C_Aon\ <br /> State^cg^Zip Bus. Ph.Q^s 9 g 4 -13 zs Alt Ph <br /> Si9natUre-----------------------„ Date cMiq) <br />j. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name VLXcvyfcx FA# <br />Address_AkC—LL. Ps-----CSncaXo co\ Bus. Phone ? 6g <br />Zip^S'Le ? Owner/Operator "OcXiA <br />Check all appropriate services provided: <br />£§zV\/astewater disposal <br />Stolid waste disposal <br />ij^Hot & Cold water for cleaning <br />O^tore dry food/supplies <br />I. S-xncCKA-r,