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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 />Owner/Operator <br /> Vehicle wash <br />Date REHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehr1 <br />p^Wastewater disposal <br />tZf'Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />Ej Electrical hook-ups <br /> Tpilet and handwashing <br />dr Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />SAN JOAQUIN <br />------COUNTY------- <br />1. To be completed by APPLICANT <br />Business Name <br />Owner/Operator Name <br />Business Mailing Address <br />CityO4g:.C.Ukr\ <br />I._________________ <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 />Y Plate <br />State^/j-Zip Ph.4?f?ff <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 pen^&esr-x <br />Signature Date J? — T''& <br />Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryNam e________Q/) fil i <^6? k~)z (\/E ///C L flf? / PA#__________________________ <br />Address /AV Bus- Phone ?T4^/< 2 ry <br />City A, f/yzip <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br /> £ >tore 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, 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 o^enshall notify the EHD immediately. <br />S i g n atu re _______________________ __