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Environmental Health Department <br />Lie. Plate # S (p 0 <br />Co c/J e <br />Date <br />Commissary Name <br />Address <br />City____ <br />3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Overnight parking <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 1 F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />------COUNTY— <br />Greatness grows here. <br />FA# <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 /> <br />| 1. To be completed by APPLICANT ~ | <br />Business Name P flM< <br />Owner/Operator Name <br />Business Mailing Address 7~ZFV <br /> <br /> CityjMlten State^ipj5^ Bus. Ph. ?/Z> ^5^-3Alt Ph. ^7O~^'7 <br />, 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 />si9nature--------------------Date //g <br /> |_2. To be completed by COMMISSARY OWNER/OPERATOR <br />_ si/// A _Bus. Phone _ <br />_________Z i p ^7 Own e r/O pe ra to r rZ <br />Check all appropriate services provided: <br />Wastewater disposal <br />p Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />----------------------------------hereby state that the information I have provided is current true and <br />correct to th^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 Ef^D-immediately. <br /> Signature.-------Date /A//- /C_____________________________________________________________ <br />L3Joj9ej:ompleted by the ^nVTieALTH jurisdiction outside of San Joaquin CoT <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 />REHS Signature <br />^Electrical hook-ups <br />^Toilet and handwashing <br />Potable water <br />Vehicle wash <br />------w P > ------- - --------------------------------------------------------------------------------------------------------------------J • J Li II IIV/I I I ICJUkJI I | | <br />:heT)est of my knowledge, and meets the California Health & Safety Cod.