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Environmental Health Department <br />Jfc... <br />tl <br />REHS Signature, <br />1868 E Hazelton Avenue | Stockton, California 95205 | T 209 468-34201 F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />------COUNTY------ <br />GceI. ns Jor<■'1 v > hf re <br />Lie. Plate # HVEAI^T. <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 />i 1. To be completed by APPLICANT_________ <br />Business Name TASU or PWW <br />Owner/Operator Name$> I H > - <br />Business Mailing Address_ 817^ SHM <br />CitySTflCWNstateCfi I.Lbus. Ph.(10T ' ICM Ph. <br />I, S I H / b H A N WAh/Tdereby 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 andaenalties/ z i . i <br /> _________.» (>3j.a5|WS- <br />2. To be completed by COMMISSARY OWNER/OPERATOR______________ <br /> Commissary Name \) n i o n Tr c/ CM n^j 6Qm rvv'&sa ___—— <br />Address nn c VNi^M iS'p Bus. Phone <br />City_S^7jf Zip Owner/Operator I I I-------- <br /> <br />Check all appropriate services provided: \\) CVS IT 0 <br />Wastewater disposal 3-compartment sink <br />Solid waste disposal Food preparation <br />Hot & Cold water for cleaning Store refrigerated food <br /> Store dry food/supplies Overnight parking <br />I IQ K O A Jdy , hereby state that the information I have provided is current, true and <br />correetto' the test of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to n>m<wJk^Tonditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owkepstetfr^rboEHD immediately. . <br /> <br /> Tro^e completedTythe ENV HEALThTjurisdiction outside of San Joaquin Cml <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 /> Date__ _____________________ _ <br /> Electrical hook-ups <br />Toilet and handwashing <br />^5 Potable water <br />/P Vehicle wash <br />i Ik S I fU (iks C' U cA>__________, nereoy state u idi u ic ii hoi 11 iduui i i i lavs pi c/vim'-.vj iv <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. <br />,y^ <br />4fno'