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i <br />Environmental Health Department <br />ier <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 1 F 209 464-0138 | www.sjgov.org/ehd <br />0D22Q <br />SANJOAQUIN <br />------COUNTY------ <br />Greotnpss grows here <br />Address I")|"1 <br />city_STZ)CKrDrv <br />Check all appropriate services provided: <br />sf Wastewater disposal <br />yf Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />>. V/rf/^A ,Q)fA <br />correct to the be? <br />operator fails to, <br />commissary awr <br />Signature <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <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 />Business Name AP NA___P V N-I A B t BH A B b'c. Plate# H VD H 5 <br />Owner/Operator Name B L \NlN SI N H <br />Business Mailing Address I $4^ AVE <br />City-MANTE<2A state^zip^£g^ABus. Ph.^20-3^ - ^/ah ph,____________ <br />. ^irVjA-------------hereby state that the above information is current, true and correct to <br />‘Afar! r a my .n0"ed?e andUagfee t0 utlllze 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 />“voS^ndSX Pem1it h0ld6r mUSt nOtify the EH° t0 nOtify thiS °ffiCe may result in Pe™‘ <br />Signature, VI A/cAtf Date <br />|~2. To be completed by COMMISSARY OWNER/OPERATOR ---------- <br />Commissary Name\jNlQN N6 6 ENTf^FA# <br />j SJZ Bus. Phone 10^ ~ 2^^- 5^ t/ <br />Zip Owner/Ooerator <br />\/\JkS H JA/L) " <br />-- Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />/‘C Vehicle wash <br />ScS-compartment sink <br />X Food preparation <br />Store refrigerated food <br />Overnight parking <br />--------hereby state that the information I have provided is current true and <br />and meets the California Health & Safety Code requirements. If the food facility <br />the conditions of this agreement, or if this agreement is modified or cancelled the <br />the £HD immediately. <br />---------------- ------------------------------Date, <br /> <br />3. Tote£ completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. | <br />The commissary is located in----------------------------------------------------County The above food facj <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 />REHS Signature