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<br />iw <br />Date. <br />AJ4 lagDate <br />DateREHS Signature. <br />.' ; ■V. :e:!S!.:-IK>W’ <br />1868 E. Hazelton Avenue | Stockton, California 952051 T 209 468-34201 F 209 464-0138 | www.sjgov.org/ehd <br />City^AarvUcft __ <br />'di! <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 />4-MrSAItJOAQUIN <br />c ou n t y-— <br />0tnCI> grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦Caterer <br />' ^secth)ns1^2. <br />feuslness NameG IjfHnS ,pl ?-?n. LI ------------- ---------LlCf' P'ate # <br />Owner/Operator Name I^<l,—------------- <br />Busiplss Mailing AddressBlAQ. \>J ------- -------- <br /> <br />tefety.Code, and San Joaquin County Environmental Health Department (EH ) q result in permit <br />Emissary is discontinued, the permit holder must notify the EHD. Failure to notrfy this office may P <br />avocation and penalties. . f <br /> faure ------ _______________________________________Date--------- 7 <br />jo?, <br />Environmental Health Departrnent <br />w <br />e^^Electrical hook-ups <br />□"Toilet and handwashing <br />Eh Potable water <br /> Vehicle wash <br />I, Lf- r. A, , hereby state that the information I have provided is current, true and <br />correctto best ofmy knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />v operator fails to comph <br />" commissary owners <br />Signature ‘ <br />'^‘issary Name, FA# <br />fess 14 2 Bus. Phone <br />/ ; Zip ^>95386 Qwner/Operator <br />Check all appropriate services provided: <br />^tf^A/astewater disposal 3-compartment sink <br />JZ-Solid waste disposal Food preparation <br />'QHot & Cold water for cleaning Store refrigerated food <br /> Store dry food/supplies /□'^Overnight parking <br />I. Mr- <br />to compty>ito4he coiyjitions oLtfis agreement, or If this agreement is modified or cancelled, the <br />wner^lallnotifwthe EWD immediataly.