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Environmental Health Department <br />Date <br />c 3 <br />OANjJUAUUIN <br />-------COUNTY-:— <br />Electrical hook-ups <br />Toilet and handwashing <br />X) Potable water <br />Vehicle wash <br />.Zip Owner/Operator <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/suppljes <br />i._ eV <br />correct pi <br />operator fails to comi <br />commissary owner sh; <br />-------Date <br />[3- Ty^g^mpieted by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in ' <br />REHS 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 />I 1. To be completed by APPLICANT [ <br />Business Name Plate# c/VlQ^xS5S~ <br />Owner/Operator Name V) /r <br />Business Mailing Address I R <br />City.MA IY16CZT State^Zip^^J^Bus Ph.°IZ/)-2>l3-frH/ Ait ph. <br /> <br /> . hereby state that the above information is current, true and correct to <br />rev™nryanBd“iUed’ ‘he mUSt n0S,y *he t0 thiS °ffiCe may result in Permit <br />Signature 13 g-tyv^ft_____________ Date /z&ZX <br />2. To be completed by COMMISSARY OWNER/OPERATOR ----- <br />Commissary Name I) lUlQ C/rll^t£______________________ <br /> AddressjJ H S- UUltfO ST bus Phone 20^1- <br />City_S 10 C/Clt; ry) zin OwnAr/Oruaratnr ""7/ A <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 />fate to------------------------------------------California Health & Safety C°de re‘’uireme"'s ^e food facility <br />So^^^^py^Sa9reemen‘-or" agreement is or cance,led. ‘h- <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd.