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Environmental Health Department <br />Date <br />3. To bei <br />REHS Signature Date <br /> Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 | www.sjgov.org/ehd <br />P<2 OSH 5833 <br />SANJOAQUIN <br />-----COUNTY— <br />Greatness grows here. <br />Lie. Plate# <br />t"Y ' -4 , <br />twu <: <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 />jL To be completed by APPLICANT <br />Business Name C) <br />Owner/OperatorName <br />Business Mailing Address Y7X? <br />CitySfef /fr^ Stated Zip^2/62 Bus. Ph^0Alt. Ph. <br />I’ Ck., 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 discontinuecphe permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation awrbnenalties. ( f \ j <br />Signature Date ® <br />2. To be completed by COMMISSARY OWNER/QPERATOR ~ <br />Commissary NameljNlON CPCTE^-INfcl T^-VC|< CS/VTSfi#__________________ <br />AddressD ll y UNIAN Bus. Phone <br />CN Zip Owner/O perator ^QS/ ~T1 <br />Check all appropriate services provided: <br />Wastewater disposal ^0' 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 />..JWA VtVA __, hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply^t^Lh^conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner sfpHrfTO^TtUe/EHD immediately. <br />Signature. Date <br />mpleted 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.