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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 />Alt. Ph. <br />2-5Date <br />Owner/Operator <br />Date REHS Signature <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 />OO'-IT'H <br />■ SAN JOAQUIN <br />-COUNTY- <br />3. 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 & 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 />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Wastewater disposal <br /> Solid waste disposal <br />..1 Hot & Cold water for cleaning <br /> Store dry food/supplies <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 with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. I <br />S i g n a t u r D a t e-^ • <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 7^47^ 1^5 V FA# <br />Address3/^ U' //7T' Bus Phone^gy- <br /> <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 />1. To be completed by APPLICANT <br />Business Name Lie. Plate it <br />Owner/Operator Name , J A C V I"/' p r^~ /\ y<J i /U J <br />Business Mailing Address <br />c11y~f state lA zip7^ bus. Ph^2oy) 7 <br />I, AL~Vj . 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 CounTyjELvironmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, tha^ermitlhdlder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. Y X | f I <br />Signature______________'' Date e I