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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 />7 7^Lie. Plate # <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 />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1. To be completed by APPLICANT <br /><>iY1C>K/-aj <br />A/\ C. <br />t/M io/J <br />SAN JOAQUIN <br />-----COUNTY------- <br />; grows here. <br />CTS-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 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 otynersftall notify the EHD immediately. / <br />Date <br />3. To l^e/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 />□'"Electrical hook-ups <br /> Toilet and handwashing <br />Potable water <br />S^ehicle wash <br />2. To be Completed by COMMISSARY OWNER/QPERATOR <br />Commissary Name z FA# <br />Address /\) Bus. Phone <br />City Zip Owner/Qperator <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br /> Hot & Cold water for cleaning <br />d Store dry food/supplies <br />i. <br />Business Name P> Q S <br />Owner/Operator Name ZS(Z \fv\ <br />Business Mailing Address / '2-72-0 <br />City State M Zip ^S^TBus. Ph.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. 7 <br />Signature fl /