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Environmental Health Department <br />Lie. Plate # *5 <br />J <br />REHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 lwww.sjgov.org/ehd <br />Electrical hook-ups <br />if Toilet and handwashing <br />fc" Potable water <br />^Vehicle wash <br />SAN JOAQUIN <br />------COUNTY------- <br />FA# <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 />I 1 ■ To be completed by APPLICANT <br />Business NameVg I C <br />Qwner/Qperator Name AAav/ S CO S M o “Hq H <br />Business Mailing AddressVa|9 | . <br />City State CA-ZiD<?5?lS Bus. Ph(2O?l Sia^aW\lt Ph. <br />l«—— -------------------------------------------------------- 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 \/c<lru I tT C Date -3-- _____ <br /> | 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name L .SpppH. <br />Address Bus. Phone <br />City ‘[■o O /< b&A Zi p 7* Own er/Operator <br />Check all appropriate services provided: <br />Wastewater disposal 3-compartment sink <br />Solid waste disposal Food preparation <br />M" Hot & Cold water for cleaning Store refrigerated food <br />Sf Store dry food/supplies Overnight parking <br />U -, 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 immediately. 1 >Signature ' Date <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.