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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 />Business Name <br />Date <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 />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />3. 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 />SAN JOAQUIN <br />-COUNTY------ <br />Greatness grans here. <br />JK, 3-compartment sink Electrical hook-ups <br />.^Food preparation Toilet and handwashing <br /> Store refrigerated food Potable water <br /> Overnight parking Vehicle wash <br />, 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 notif^Ke^HD immediately. <br />Signature^ <br />Lie. Plate # <br />1. To be completed by APPLICANT <br /> / ^5 ck "ToJa nd g <br />Owner/Operator Name <br />Business Mailing Address 5- Q. <br />City SWhW* State rift Zip 9^/5 Bus. Ph^ 0*11 fo^ftAlt. Ph. <br />I,, 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 / <br />Signature ------ Date 7 /ff 8/g 6.___ <br />2. To be coTnpleted by COMMISSARY QWNER/OPERATQR ~ <br />Commissary Name FA# <br />Address_/ S ( F mXn ______Bus. Phone_ S( £ 72^7 0'2 <br />City W Zip Owner/Operator_ > C ^(tJr-XCY <br />Check all appropriate services provided: <br />Jgf Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I.____________________________