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SAN JOAQUIN <br /> Environmental Heann <br /> - <br /> COMMISSARY AGREEMENT <br /> Nlnt)ilr. 1-crud Facility 0 Catorot sectrvn =� <br /> also corn/rlete <br /> Comulele sections f amt2 N your cr�rtrrn,:;:,art'r,10,3fefl vUfsido cel Safi Jnagrnn Gounl y ----f�� <br /> [ 1. To be completed by APPLICANT _-- ;* _� <br /> r I_rc Flat —. <br /> Business Name_ -- <br /> Owner/operator <br /> Business Mailing Address <br /> _- - — — <br /> , Rei Z.Zf - , W- Alt. Ph-_�------ <br /> Crn fry: _Statq� 7ip_!`� ?�—E3us. Ph. 7 7 — <br /> r hereby state that the abuve in is current, true and correct to <br /> I {� ----- y approved <br /> the best of my kno�+edge and agree to util.7e rdance <br /> m a rovadr DP'mrtn enllr(EHD))requ�ements with allfo'he use of the <br /> Safety Cede, and �n Joaquin County Environmental He P result in pr rrnit <br /> commissarti is d catinued, ttrc permit holder must notify the EHD. Failure t<� notify this office may <br /> revocation and * ,aities. <br /> Date_ -- -- <br /> Sianatune — --y- —F2—. T be completed by COMMISSARY OWNER/OPERATOR <br /> FP`s <br /> Ccmmissary Name <br /> Address 1 t J 4 Bus. Phone <br /> — r �) ' ZIP 1.�-�=Owner/ �_ �Operator f PP D C <br /> City\I l . t .k- I� <br /> Check aii appropriate services provided: W <br /> \1 3-compartment sink Electrical hook-ups <br /> -� `,"dastewater disposal P <br /> Solid waste disposal El Food preparation <br /> Toilet and handwashing <br /> 4W Hot & Cold water for cleaning ❑ Store refrigerated food Potable water <br /> Store dry food,'suppires El Overnight parking Vehicle wash <br /> 1 �^.�I­ :I �Qb hereby state that the information Irhave provided is current, true and <br /> correct to tF,e best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comply/�,-t,f/ <br /> to the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary or er the EHD immediately. <br /> Signature_ Date <br /> 13. 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 & Safely 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__ Date_ <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />