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Environmental Health Department <br />I <br />Lie. Plate # <br />Date I 1 2 I / Z <br /> <br /> <br />I- i-x, -"^0^6Date <br />IREHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />V\Xc!1**sFA#__________________ <br />5 <br />’I <br />i1' <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 /> <br />RAMS® J5 '2-^; jm <br />OM^Iectrical hook-ups <br />GPToilet and handwashing <br />dr'Potable water <br />^bVetuda. <br />SAIWOAOUIN <br />y ^^7 COUNTY <br />Greatness grows here. <br /> <br /> <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 />Business Name It of CofFtc <br />Owner/Qperator Name ban if) Di CCI— <br />Business Mailing Address 5^X3 HlH Ci f <br /> <br />____StatejTA Zip ^SZIObus. Ph. Alt. Ph._________________ <br />)*—lyQnirjtC , 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. <br />Signature <br />Commissary Name <br />Address.\\Q €a \bdCcxko Bus. Phone <br />City—SA-CTk Zip Owner/Operator <br />Check all appropriate services provided: <br />□^Wastewater disposal CKf-compartment sink <br />OK^olid waste disposal ETFood preparation <br />O^Ffot & Cold water for cleaning Cl^Store refrigerated food <br />Ek&ore dry food/supplies Q-Ovemight parking <br />'■ —. 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 with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shalLwtify the EHD immediately. <br />Signature