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Environmental Health Department <br />Lie. Plate # <br />Date <br />3. To be coi <br />REHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehci <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />dAN>JUAUUIN <br />----COUNTY- <br />□£3-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 /> Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />^0 Vehicle wash <br />revocation and penalties. <br />Signature_______ <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />11. To be completed by APPLiCANT <br />Business Name. <br />Owner/Operator Name_ g-ITft _______________ <br />Business Mailing Address, MVNIWD ________________ <br />City 5^17)M State ZA Zjp^l^l^ Bus. Phffi^foStR: Ph" <br />i Efifr Silva . 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 /> Date_ 0H|0lg <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name, 0Nl/)N TTjJCK- CwJrw________ <br />Address DB S VNllON ST Bus Phone/?. | 2^? r 5^ IV <br />City '$77) fV Zip 7^0ip Owner/Operator J 1^7^£ T1 0 <br />Check all appropriate services provided: <br />m Wastewater disposal <br />Solid waste disposal <br />xf Hot & Cold water for cleaning <br />u Store dry food/supplies <br />. __ Lx. A—. XL _ L_ — — A _ r 1... . I- ■ <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 EHQ immediately. <br />Signature | Date 0^1 I <br />leted 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.