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Environmental Health Department <br />I <br />Complete sections 1 and 2. <br />Lie. Plate# <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 |F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />------COUNTY------- <br />:_________fa#________________ <br /> <br />Bus. Phone 5^ / Z $ I - <br />Owner/Operator <br />Electrical hook-ups <br />Q Toilet and handwashing <br />ii/T Potable water <br /> Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed ^APPLICANT ' <br />Business Name^Mf ('Mfe// f/f), <br />Owner/Operator Name fyfkYf-C'V _________ <br />Business Mailing Address_ ^ilfVlM \MM^ __________________ <br /> ____.State&LZip/E?360 Bus.PhM^JIH-ft^Alt.Ph. <br />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, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties z/Z'/ / / <br />Si9natUre—Date /ZZlZ <br /> [2, To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name< <br />Address <br />City Zi| <br />Check all appropriate services provided: <br />Z Wastewater disposal <br />j. ’ Solid waste disposal <br />Hot & Cold water for cleaning <br />T Store dry food/supplies <br />X , <^icuy Oldie nidi me imormaiion I nave provided is current, true and <br />correcTTo 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 />CnrnmiQcan/ ruunor cRoll tTLJr^ -j:i. . * ’ <br />Date <br /> LT^To^ecompletedby the ENV HEALTH jurisdiction outside ofSan JoaquinCor] <br />commissar requirement in'california Health & Safety Code. The above^heXlZerar^vXTe'at She <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature <br />3-compartment sink <br />E^Food preparation <br />Ilf Store refrigerated food <br />Overnight parking <br />--------, hereby state that the information I have provided is current, true <br />:o the best of my knowfedge, and meets the California Health & Safety Code requirements' <br />commissary .owner shall notify the EHD immediately. <br />Signature ~-------