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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 />Date 7^ <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />FA# <br />Vehicle wash <br />m <br />Date <br />Date REHS Signature <br /> <br /> <br /> <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />C R f^? <br />____Bus. Phone <br />Owi^er/Operator_____ <br />Z <br />0 <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 lwww.sjgov.org/ehd <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 />Lie. Plate # gd) U 6 3 <br />SAN JOAQUIN <br />------COUNTY <br />Greatness grows here. <br /> 3-compartment sink <br /> Food preparation <br />Store refrigerated food <br />sQ Overnight parking <br />I, , hereby state that the information I have provided is current, true and g < <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility o F <br />0) 3 <br />H V O <br />q£* <br />O IQ <br />X m «- O rn _ <br />o 2 O <br />So m <br />o <br />7) m <br />> <br />2 <br />O\U%~- /~2U[Oi <br />Commissary Name P | c IC yP GO <br />Address 2/7/^, I VZT <br />City Zip Q < <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 />1. To be completed by APPLICANT <br />BusinessName ST/V ^7-^ <br />Owner/OperatorNam e J^') L2 K pi ■ p <br />Business Mailing Address 3 Z o-5 M <br />City 51/ stated Zip /z^ Bus. Ph^ 1/ FJ-<$6l?/Alt. 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_ <br />z = <br />O m <br />> <br /><0 > <br />IQ <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.