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Environmental Health Department <br />S'fa / <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Bus. Ph. Alt. Ph. <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 />Electrical hook-ups <br />[^Toilet and handwashing <br />Et Potable water <br />Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />f^JB-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />'^Overnight parking <br />________________• hereby state that the information I have provided is current, true and <br />correct to the test of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />SAN JOAQUIN <br />-COUNTY- <br />Greatness grows here. <br /> FA#_______________ <br />Bus. Phone_ <br />Owner/Operator_ (WtoiA Morgue?- <br />2. To be completed by COMMISSARY OWNER/QPERATOR <br />Commissary Name (5 / (Jao. Ho <br />Address_ <br />City Zip <br />Check all appropriate services provided: <br />[^Wastewater disposal <br />[$[ Solid waste disposal <br />fZkHot & Cold water for cleaning <br /> Store dry food/supplies <br />i,____________________________ <br />correct to the test of my kn< ~ <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shalkjotify the EHDxTfJ^dlately. <br />S i g n a t u re a te <br />3. To be completed by the Efflv'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 />Lie. Plate#. 5 Zo <br />1. To be completed by APPLICANT_____ <br />Business Name Z-l i <ro 3^ i / < hruch * <br />Owner/Operator Name. >^17 /) < <br />Business Mailing Address 3^ fcj CO t LUO-CJ <br />City state Zip <br />I, A' oc S, 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