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c <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date Signature <br />/t huAd <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 />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />3. Tg^<Qmpleted by the ENVHEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in County. 1 he 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 />Lii ix: <br />P Electrical hook-ups <br />P Toilet and handwashing <br />Potable water <br />S Vehicle wash <br />[3 Wastewater disposal <br />pa Solid waste disposal <br />pP Hot & Cold water for cleaning <br /> Store dry food/suppli^ <br />i, VteSUCgy <br />correct to the best of m <br />operator fails to complyswith the ci <br />commissary owner shall nbCtfy/hfe^ <br />Sig nature <br />1. To be completed by APPLICANT ________ <br />Business Name I Or Vq I" Cf________ <br />Own er/Ope rato r N a me n A V Ji mCt) C ZL_________ ___ <br />Business Mailing Address, <br />City n State Cfl Zip Bus. Ph.Ait. Ph WlH&- <br />I, RnC . 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. t . <br />SAN JOAQUIN <br />-COUNTY- <br />Greatness grows here. <br />Lie. Plate #_ <br />2. To be completed by COMMISSARY OWN E R/O PE RATO R______________ <br />Commissary Name, <br />Address nn Bus. Phone <br />City /O Zip Owner/Operator C>S i fTM <br />Check all appropriate services provided: <br />E3''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 />ited^e, and meets the California Health & Safety Code requirements. If the food facility <br />xnditions of this agreement, or if this agreement is modified or cancelled, the <br />iwfe immediately. / . ,