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‘ I <br />Environmental Health Department <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 />Lie. Plate #Business Name <br />Date <br />Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />REHS Signature Date <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 />/ c — <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <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 />3 Potable water <br />Vehicle wash <br />SAN JOAQUIN <br />------COUNTY------- <br />Greotnes? grows nprp <br />.... ________FA# <br />Bus. Phone <br />3 3-compartment sink <br />0 Food preparation <br /> Store refrigerated food <br />Q Overnight parking <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 notify the EHD immediately. <br />Signature <br />2. To be completed by COMMISSARY OWNER/QPERATOR <br />Commissary Name_ <br />Address_ L <br />City t-c k/_______Zip Owner/Operator_ <br />Check all appropriate services provided: <br />£3 Wastewater disposal <br />Of Solid waste disposal <br />0 Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. VM i \\\ S i Ficc^i G <br />tt-z ^2a/ z/ <-/ <br />Owner/Operator Name <br />Business Mailing Address Z76 <br />City Stated Zip ^yS'^-Z Bus. Ph.^b^^^yAlt. 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