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tMMJUlXJ <br />Environmental Health Department <br />Comi'lt tf sections 1 and 2 If your commissary is located outside of San Joaquin County also complete section 3 <br />Date <br />Owner/Operator <br />Vehicle wash <br />Date <br />Dale REHS Signature <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 1 F 209 464-0138 lwww.sigov.org/ehd <br />r <br /> <br /> <br />Commissary Name <br />Address <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />commissary owner shall polity the EHD immediately <br />S i g n a t u re —-------------- <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1 <br />SAN JOAQUIN <br />C QU N1 Y <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />O'Overnight parking <br />. hereby stale that the information I have provided is current, true and <br />FA# <br />>> <br />Lie Plate# H <br />/6 Bus Phone <br />City Z<>j Zip Owner/Operator <br />Check all appropriate services provided <br />Wastewater disposal O <br />Solid waste disposal <br />Hol & Cold water for cleaning <br />Store dry food/supplies <br />of m/Sowledge, 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 /> <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co, <br />The comm.ssary is located m ___________________________________County The above food facil,’y rneets ,he <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 />I. —-- <br />correct to the best of <br />1. To be completed by APPLICANT <br />Business Name <br />Owner/Operator Name G <br /> Business Mailing Address_B3HA <br />City^^oMyn StateCfl ZipffS^ll Bus. Pfr | ^ -^31 Alt Ph <br />*■. oo / czx ,G -SuJT iq . hereby stale that the above information is current true and correct to <br />the best of my knowledge af\yagree 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 c/ the <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in perm ! <br />revocation and penalties. <br />Signature <br /> <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR