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f- -4 <br />Environmental Health Department <br />S-2A- 2-0Date <br />Owner/Operator ft <br />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 />dd^3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Overnight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />A^EIectrical hook-ups <br />Toilet and handwashing <br />c^^Potable water <br />CE^Vehicle wash <br />l( , 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 />SANJOAOUIN <br />-----COUNTY- <br />G,,-. /. . <br />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 />CL(L Lie. Plate # V X M 0^9 <br />Gca. rol<|n CciwipaS <br />2/To be completed by COMMISSARY OWNER/OPERATOR___________ <br />tcX <ry>_____FA# <br />U>^-y___________Bus.Phone <br />■ LG <br />aC , r <br />Commissary Name <br />Address ‘2-^0 0 <br />City Zip ‘{ SIX) $ <br />Check all appropriate services provided: <br />Wastewater disposal <br /><^Solid waste disposal <br />JSrHot & Cold water for cleaning <br /> Store dry food/supplies <br />iKa-ca fegrc-enOS <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner s^all notify the EHD immediately. <br />Signature <br />a. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <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 />Business Name <br />Owner/Operator Name <br />Business Mailing Address <br />City State Cig- Zip gl 5 2-1 O Bus. Ph.Alt. PhC^l? (o6&'b(p°(l <br />I. Cnrnli no 0(XYnpOS . 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 /pst notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature