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Environmental Health Department <br />1,Tobe>ETil <br />r7)l^ck Plate# <br /> Date <br />Date REHS Signature. <br />revocation and pi <br />Signature <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 />■>! 'If-S'- U<.?»VS here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer - <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />2. Tosba <br />Commissary Name L A CM7.^ FA# 00^7 ^23 <br />Address_ Bus. Phone_ Z/2-- <br />City Zip 9-5 SSOQwner/Operator -------- <br />^Electrical hook-ups <br />ga^oilet and handwashing <br />Potable water <br />GS^Vehicle wash <br />9j5 $C5»QOwner/Operator <br />Check all appropriate services provided: <br /> 3-compartment sink <br />O Food preparation <br />O Store refrigerated food <br />ffi^Overnight parking <br />, hereby state that the information I have provided is current, true and <br />" ‘ ‘ . If the food facility <br />or if this agreement is modified or cancelled, the <br /> Date 2- __________ <br /> 3. To b^mpleted by4feENVH£Ata?H iurisdiction<outside.ofeSan. Joaquin Co. ' <br />The commissary is located in County. The above food facilitymeets 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 />Business Name / X <br />Owner/Operator Name d <br />Business Mailing Address t^cLc y <br />City P7! r Q State CAZip S^S3~Bus. Ph.Q Alt. Ph.------------------------------- <br />I. 73? . 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 />lalttes. i • I . <br />Wastewater disposal <br />Solid waste disposal <br /> Hot & Cold water for cleaning <br />O Store dry food/supplies <br />] Vl^L, fTAvY"l • nereoy siaie mai me imumiauMii ■ nave H.e.<UeU - <br />correct to the best of my knowledgeland meets the California Health & Safety Code <br />operator fails to comply with the conditions of this agreement, <br />commissary owne<7shall notrfyTJie EHD immediately. <br />S ig natu re —