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Environmental Health Department <br />] <br />Date <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 /> Electrical hook-ups <br />^.Toilet and handwashing <br />■^-Potable water <br />3 Vehicle wash <br />SANJOAQUIN <br />------COUNTY------ <br />Greotnest grow: n-?- <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />Pl. To be completed by^QiRRlJCANT | <br />Business Name p/ /g / <br />Owner/Operator Name <br />Business Mailing Address 5"37 5- <br />City SkxhWA State r^’Zip <br />I.__________________ __________________ • <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 />Lie. Plate# H <br />FA# <br /> Zip <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I.__________________________ __ ___ <br />correct to toe best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />commissary owner shall notify <br />Signature <br />3-compartment sink <br />.^Cpood preparation <br />O Store refrigerated food <br />C Overnight parking <br />. hereby state that the information I have provided is current, true and <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />f£l£HD immediately. 1 y <br />('Z& <br />3. To be completed by the EN\Z 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 />Bus. PhjO<dp9g-fr?9pAlt. Ph. <br />• hereby state that the above information is current, true and correct to <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. <br />revocation and penalties/ / <br />Signature^^^U^-------=Date ? / <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name LdyKlVS A <br />Address—Bus. Phone <br />City Zip Owner/Operator