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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 />Signature Date <br />FA# <br />^Vehicle wash <br />Date <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 />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 />pS* Electrical hook-ups <br />[^Toilet and handwashing <br /> Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />-COUNTY— <br />Greatness grows here. <br />3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />IJSt Overnight parking <br />_______, 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 END immediately. <br />Sig natu re_____ <br />3. To be completed by th^tNV HEALTH jurisdiction outside of San Joaquin Co. <br />1. To be completed by APPLICANT <br />Business Nam, Lic Plate# <br />Owner/OperatorName < f&VKf "__________________________ <br />Business Mailing Address_ by3^ t/o. <br /> State ^Zip fCZ/Z. Bus. Ph^r^z/V/-^^ Alt. Ph. <br />I, /f-rY Ii'. hereby state that the above information is current, true and correct to <br />th^/besf of my knowledge ah$ 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 p^nfelties. <br />____________________Date 3____________ <br />2. To be completed by COMMISSARY OWNER/QPERATOR <br />CommissaryName <br />Address jrf A -Bus. Phone <br />City W; Zip A/ZZi- Owner/Operator <br />Check all appropriate services provided: <br />jg_ Wastewater disposal <br />QC Solid waste disposal <br />pQ' Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i. __________