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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 /> <br />1 <br />Date <br /> <br />2. To be con J•RY <br />^4Date <br />i 3. To be <br />REHS Signature Date <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 />0)51. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />Q C U N T Y <br />______Bus. Phoni <br />Owner/Qperator <br />□- Electrical hook-ups <br />C3/toilet and handwashing <br />□'-Potable water <br /> Vehicle wash <br />Commissary Name C O f KY <br />Address .5 5 k z? <br />City Lt> J;Zip ^5X^0 <br />Check all appropriate services provided: <br />EKWastewater disposal □/3-compartment sink <br /> Solid waste disposal zFood preparation <br />Q- Hot & Cold water for cleaning ' JStpr-e refrigerated food <br />□" Store dry food/supplies □'■’Overnight parking <br />I,-t , 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 ' diately. <br />Signature_/7 <br /> <br />Business Name. Sfr-Xyi de. I orc <br />Owner/OperatorNam e ! Cit'/ ft r r t) n //, ? <br />Business Mailing Address, ^5/3 Atr y 0 L~h <br />City LcdJ/State Zip 751^0 Bus. Ph. /6 5 7c)7 9,55^11 Ph. <br />I, , hereby state that the above information is current, true and correct to <br />the Best of rny 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. <br />Signature /J A Date_ c>6 - <br />y ~ ------------------------------------------- <br />I o be <br />Lie. Plate # O <br />Cd) Un 4________________ <br />FA# <br />Tzcfi) <br />I id Of/IsaA/CC <br />V