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Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />■tt Date <br />Owner/Operator <br />tely. <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 /> Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br />FA# <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />------COUNTY- <br />Gregtness grows here <br />1. To be completed by APPLICANT__ <br />jg Mexicana <br />3.TcTbe 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 />Lie. Plate # Business Name <br />Owner/OperatorName Cr<<>l'a.n __________________________________________________ <br />Business Mailing Address 3^-1 2. VoOgVo C'C <br />City StatefCA Zip^2-l2 Bus. Phf2^^5 Alt. Ph. <br />I,_____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, tbejpp^Qjit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties, q <br />Signature <br /> Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notifvtl <br />S i g n a t u re__________ <br /> 3-compartment sink <br /> Food preparation <br /> Sto^r refrigerated food <br />{Z^vernight parking <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name, <br /> Address Fl Bus. Phone <br />City Zip <br />Check all appropriate services provided: <br /> Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />l WfWa <br />correct to the best of my knowledge, aner me