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City <br />Commissary Name <br />Addres g9 <br />Zip c/5"-g S— Owner/Operator <br />la 3-compartment sink <br />O Food preparation <br />O Store refrigerated food <br />is Overnight parking <br />Da Electrical hook-ups <br />ria Toilet and handwashing <br />pi Potable water <br />011 Vehicle wash <br />tfiTi <br />,°(= SAN)JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Greatness grows here. <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 />To be completed by APPLICANT <br />a/Rf—ico Lic. Plate # <br />Alt tie b-.),) 0/ - '?iCk;2 / <br />City i Stateal-Zipqt.o110 Bus. Ph.,2S- (24,3 - 7V Alt. Ph. <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 />Signatur //— <br /> <br />To be completed b COMMISSARY OWNER/OPERATOR <br />Check all appropriate services provided: <br />Business Name Cda,e4p.d./ /21- <br />Ovvner/Operator r\lame <br />Business Mailing Address W• <br />Ea <br />I, /kik( v /9 lit 0 <br />Igl Wastewater disposal <br />)5) Solid waste disposal <br />Hot & Cold water for cleaning <br />o Store. dry food/supplies <br />awe/ felt Abil-tlaikz._ <br />correct to the best of my knowledge, <br />operator fails to comply with the c <br />cornmissaryner shall notify th <br />Signature <br />, hereby state that the information I have provided is current, true and <br />a <br /> <br /> ets the California Health & Safety Code requirements. If the food facility <br />itions of this agreement, or if this agreement is modified or cancelled, the <br />HD immediatel <br />Date / <br />3. To be completed 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. <br />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd