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Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />0 <br />Date <br />Date REHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 |7F 209 464-0138 | www.sjgov.org/ehd <br />Environmental Health Department <br />FA# <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SANJOAOUIN <br />------COUNTY------ <br />Greatness grows Sere. <br />S 3-compartment sink <br />Food preparation <br />c/ptore refrigerated food <br />0 Overnight parking <br /> Zip <br />Check all appropriate services provided: <br />□/Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Efstore dry food/supplies <br />I,________ <br />c________ , w . <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 />Signature ________________Date_ p// ------- <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 />G3/Electrical hook-ups <br />[^Toilet and handwashing <br />Potable water <br />IZ^Vehicle wash <br /> , hereby state that the information I have provided is current, true and <br />correct to the bes7oFmy"knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />Lie. Plate #_ 0055 5US <br />1. To be completed by APPLICANT <br />Business Name VYViW) CWfA <br />Owner/Operator Name <br />Business Mailing Address tAOY L- <br />City rA.a.v\\-\ State eftzip T Bus. Ph. -VS 3-^SOQMt. 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 penalties. <br />Signature "Date, <br />2: To b^hpteted by W^MISSARY OWNER/OPERATOR <br />Commissary Name a / (■Ccfrn(‘^ ) ny ___ <br /> <br />Address ^0 S. Y Bus. Phone <br />City Zip Owner/Operator