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Environmental Health Department <br />Lie. Plate # <br />.ZiP. <br />Date <br />Date <br />REHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />_Bus. Phone <br />Owner/Operator San\ <br />Electrical hook-ups <br />□^Toilet and handwashing <br />□^Potable water <br />BrVehiolo wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ❖ Caterer <br />SANJOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />I 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 />15 J© <br />Business Name <br />Owner/Operator Name <br />Business Mailing Address <br /> C|ty---------------------------State Zip Bus. Ph.Alt Ph. <br />**■----- ---------------------------------------------------- - 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 <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />11. To be completed by APPLICANT <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name clovwxtxxokX-S V.Vw^FA# <br />Address WQ k) , C' <br />City CY_Zip 9$7-07 <br />Check all appropriate services provided: <br />S^Wastewater disposal 0^3-compartment sink <br />Solid waste disposal OKFood preparation <br />UKHot & Cold water for cleaning EKStore refrigerated food <br />B^Store dry food/supplies Overnight parking <br />-----SqCxCX/xq , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and meets 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 owner shall notify the EHDJmmediately. <br />Signature.