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COMMISSARY <br />c/-Z <br />REHS Signature. <br />1 <br />____ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Mr.. * M' • ^IM -mi <br />Lie. Plate # <br />KJQ______ <br />OVVNER/OPERAI2R <br />f:C^//(L -FA#- <br />Bus. Phone <br />Owner/Operator------- <br />Commissary Name <br /> Ad d re ss______ <br />Citv ___Zip__^222i <br />Check all appropriate services provided: <br />p Wastewater disposal 3-compartment sink <br />CJ Solid waste disposal a Food PreParatlon <br />9 Hot & Cold water for cleaning □ Store refrigerated food <br />□ Store dry food/supplies ® Overnight parking ( have provjded is current, true and <br />'■ thTcalifom'ia Health & Safety Code requirements. <br />zas «—5 - «—• .... ’ <br />\ x To M mmpl.iK EN V HgTm jurisdiction oulside of San Joaquin Co J <br />—~ ’ County. The above food facility meets the <br />lomX^Zirements in' checked services are available at the <br />above Emissary. Please notify EHD if the status of the.r operating permit changes. <br /> Date <br />SAN JOAQUIN <br />___COU N1V <br />[^ Electrical hook-ups <br />Toilet and handwashing <br />{^Potable water <br />{^Vehicle wash <br />If the food facility <br />j or cancelled, the <br />Ph-___—----- T <br />------- nt true and correct to <br />iation is current Jrue^ He3|(h <br />If the use <br />COMMISSARY AGREJ^ENT <br />Mobile Food Facility ♦Cater <br />C„SeCr,or^^^ <br />| 1. To be completed by APPLIQ^^ £ <br />BusinessName \ ''' 4 ' f- 61 <br />Owner/Operator Name__AAlLkiy^— <br />Business Mailing Address. <br />City <br />Environmental Health <br />Comp^ section^ <br />Statd^Zip A£B>BUS- Ph'------^information is current true---He3|th a <br />Safety Code, and San Joaquin County Enivir the EhD. Failure to n y <br />commissary is discontinued, the permit holder must y <br />revocation and penalties.-^ Date_____2J-SJ-------- <br />Signature / ' —Q-^------------------------------- <br />| 2. To be compJetedTy^COMMlSSA^