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Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />Lie. Plate # <br />laities. <br />Owner/Operator <br />7 ~4-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 />JZI 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />,0' Overnight parking <br />0- Electrical hook-ups <br />Toilet and handwashing <br />0 Potable water <br />Vehicle wash <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Bus. Phone <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />------COUNTY------ <br />Business Name <br />FA# <br />,4^7 <br />Date £/• <br />Commissary Name <br />Ad d ress y.rJ <br />at. f <br />Owner/Operator Name Jvs <br />Business Mailing Address 7 73 5^ f SA <br />City state T'a Zip Bus. Ph. £<? Ph. <br />I, ’ herebV 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 anckp <br />Signature <br />r ',/-7y/7//. ((42f S, <br />City 6-7 1 Zi p yY///} <br />Check all appropriate services provided: <br />Wastewater disposal <br />£3 Solid waste disposal <br />|Xl' Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. .yXz-Z , 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 EHD immediately. <br />Signatu re________// <br />________ / _______________________________3. To be completed by the ENV44EALTH jurisdiction outside of San Joaquin Co.