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Environmental Health Department <br />Date <br />REHS Signature. <br />^Electrical hook-ups <br />gSCjoilet and handwashing <br />x^CPotable water <br />^Vehicle wash <br />209 468-3420] F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />-----COUNTY------ <br />Grear.ficss ■;'< O'.vs he- ~ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T <br />‘ SAN JOAQUIN <br />Commissary Name <br />Address; 7-^ 00 <br />City SfocHfoA Zip <br />Check all appropriate services provided: <br />^S-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />£3 Overnight parking <br />j^OWastewater disposal <br />□^Solid waste disposal <br />Cpf-Hot & Cold water for cleaning <br /> Store dry food/supplies <br /> hereby state that the information I have provided is current, true and <br />correct tXbest of my Fnowiedg^ 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 /> Signature_____________ZO,----------- ------------------------------------Date <br />37 fo beTompleted by theYNVYEALTH jurisdiction outeide of San Joaquin Co, <br />. . . . . County. The above food facility meets the <br />commissary retirements 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 /> Date <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1 To he completed by APPLICANT <br />Business Name P G_i Z < tC €■ ' <. i Vg --------------Lie. Plate #—H Fl------ <br />Owner/Operator Name, V\ n - bO-i yrKTO /' B <br />Business Mailing Address ci 3H -Fen --------------------------------------------------------------------- <br /> City IvvUviKCG State CWZipJi^Bi^Bus. Ph.Alt. Ph. 7C.L" 33(? / <br />I, IsTj'i J A (PC _______1 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. , o <br />Signature //ZdT --------------------------------------Date--------~ ----------- <br />2. To be completed by COMMISSARY OWNER/OPERATOR----------------------------- <br />Im Corfwacq fa#__________________ <br />U/a-y Bus. Phone YOQ ------ <br />Owner/Operator 6^' ■ 'ChiQ1' /A-fZ-HC-fF'----