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Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate # <br />Date <br />£■ K, (U/Liy)" <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 />S Electrical hook-ups <br />I3 Toilet and handwashing <br />[3 Potable water <br />Q Vehicle wash <br />FA# <br />Bus. Phone <br />OA/ner/Operator^ <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 />SAN JOAQUIN <br />-COUNTY- <br />Greatness grows here. <br />City Zip <br />Check all appropriate services provided: <br />H Wastewater disposal <br />0 Solid waste disposal <br />0 Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i Cgx/x///:~ <br />3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />0 Overnight parking <br />______________________ , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, andmeets 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 (X^pter shall notify the^tHD immediatt <br />Signature Date <3 " <br />1. To be completed by APPLICANT <br />BusinessName <br />Owner/Operator Name_ <br />Business Mailing Address <br />City STOiTTP State Ch Zip Bus. Ph.-7 ^>8 Alt. Ph. <br />i, JEW-/ PlfM, 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 J1 Date 3 II <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Add ress