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03 <br />Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate# <br />6Date <br />1 <br />WZ <br />Owner/Operator i 1 rfvx <br />Date <br />REHS Signaturt Date <br />Electrical hook-ups <br />S Toilet and handwashing <br />8^ Potable water <br /> Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />------COU NTY------- <br />Greatness grows here. <br />$'i 3-compartment sink <br />Food preparation <br />l>8 Store refrigerated food <br /> Overnight parking <br />I. tVerxAirV)4?, 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 ownersfialj. notifytl^EHp immediately. . <br />S ig n atu re D ate <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in Y■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 />Commissary Name <br />Address_ <br />City &crKd<4 Zip tO <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />2S Store dry food/supplies <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />2. To be completely COMMISSARY OWNER/OPERATOR <br />1. To be completed by APPLICANT______________ <br />Business Name (7 SA L-LC <br />Owner/Operator Name J c o V_______________ <br />Business Mailing Address 12-S- j fJ- S'T <br />City StateCA Zip S~3^Bus. Ph. SAlt. Ph. // <br />I, Ju , 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 hp^fTnust notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties, <br />Signature <br />_____________FA#______ <br />Bus. Phone CIO TjOCd