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Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate# <br />Alt. Ph. <br />'i <br />ipti <br />Date <br />pleted by the ENV HEALTH jurisdiction outside of San Joaquin Co.3. To b <br />REHS Signature.Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <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 />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />-COUNTY— <br /> Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />tf^/ehicle wash <br />I have <br />2. To be completed by COMMISSARY QWNER/QPERATOR______________ <br />Commissary Name, U 0 O (V/pr/r>‘\ ft/ro/FA# <br />Address. H i ~l 3 ■ U II) 16 D Bus. Phone. 2CA <br />City O Zip C|\S <3 0 QpOwner/ODerator 05 I Q <br />Check all appropriate services provided: <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 />correctfoo the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply wij <br />commissary owner si <br />Signature <br />Wastewater disposal <br />Solid waste disposal ’ <br />Hot & Cold water for cleaning <br />'□ Stone dry food/supplies <br />i, ooM <br />Date, <br />le^PfS^ions of this agreement, or if this agreement is modified or cancelled, the <br />ne EHEJ immediately. / / <br />1. To be completed by APPLICANT______ <br />Business Name <br />Owner/Operator Name Lt\\(X QVAT______________ <br />Business Mailing Address. W ftWWJ (A <br />City StateCfo Zip ^520H _Bus. Ph. <br />i. Ll Vi Cl \)\OCL , 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 />Sig nature