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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 />^/l 7-/ZCDate <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 /> Bus. Phone <br />Owner/Operator___ <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Electrical hook-ups <br />Toilet and handwashing <br />jd^otable water <br />^3 Vehicle wash <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <0 I________________FA# — <br />Bus. Phone <br />Qwner/Operator TS* <br />Commissary Name L <br />Add ress I (1 I <br />J- \ C <br />SAN JOAQUIN <br />■COUNTY <br />Creatness grows here. <br />City. <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Overnight parking <br />I , hereby state that the information I have provided is current, true and <br />correcTto the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />Ma / <br />_____Zip_ <br />jgf Wastewater disposal <br />Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry foo^upplies <br />Lie. Plate# <br />1. To be completed by APPLICANT_____________ <br />Business Name HnPE I O <br />Owner/Operator Name 'PACY PffTCMp <br />Business Mailing Address tyACO C"t- <br />City Stated Zip ^5350 Bus. Phfe\D)bCO 1533 Alt. Ph. <br />l , hereby state that the above information is current, true and correct to <br />the best of my knowled^J 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. \ 1Signature'Date | R ------- <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner/^hall notify-the EHD immediatel <br />S i g n atu re <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin CoY| <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.