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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 />Date <br />FA# <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 />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br /> 3-compartment sink <br />’^3' Food preparation <br />fcp Store refrigerated food <br />. KTOvernight parking <br />3. To be completed by the EN\Z 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 />The' <br />SAN JOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />" rn6reby state th^f the information I have provided is current, true and <br />Lie. Plate <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 EHD immediately. <br />S i g n atu re D a te <br />Commissary Name <br />Add ress 3(9 ( Z- <br />City ^00^0(3 <br />Check all appropriate services provided: <br /> Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br />Store dry food/supplies <br />2. To be completed by COMMISSARY OWNER/OPERATQR <br />-Autzj /SVC <br />vAZa-T O PO Bus. Phone <^-9 S 16^ <br />Zip Qwner/Qperator 0 c o <br />1. To be completed by APPLICANT <br />Business Name^~]of~ £ YM | TxnQ. <br />Owner/Operator Name <br />Business Mai ing Address_ 3^ [DO fijci .___________________ <br />City S-tQC State Qg.Zip^bnlO.rBus. Ph.|OT^qq~fe^ Alt- <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. i 1 <br />S i g n a t u D a t e_ ]ZICII MM