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r- <br />Environmental Health Departmentr <br />0 <br />IG? -Date <br />Date <br />REHS Signature <br />4S^EIectrical hook-ups <br />^j^Toilet and handwashing <br />^^Potable water <br />^Jpyehicle wash <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 1 F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />SANJOAOUIN <br />■-COUNTY-- <br />Gi/h?ss l/i i'ws In-i <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 />correct to the besl of my knowledge, and meets the California Health & Safety Code requirements. I , <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To: be completed by APPLICANT 7 ZZZ <br />Business Name^L£> yviU,trg. y Lie. Plate# ^&<TS{cS'l8 <br />Owner/Operator Name__5>Ox~\ 0 IVQlA _______________________________ <br />Business Mailing Address i cc*-^ ______________________________ <br />City Stated Zip Bus. Ph. Alt. Ph. <br />I, 0 Sx-rtH | Ifr-rx , hereby state that the above information is current, true and correct to <br />the best or 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 /> <br />2. To be co m p I eted by COMM IS SARY OWNER/OPE RAT 6 R <br />CommissaryName __ <br />Address Bus. Phone <br />City Zip T5ZOS Owner/Operator <br />Check all appropriate services provided: <br />^/'Wastewater disposal <br />cfilSolid waste disposal <br />JJ^Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, _____-_____-________ - ,X, X -.X rx <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 shalln^tify the EHD immediately. <br />Signature. --------- ------------------------------------------Date--------__ <br />3. To be bompleted 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 /> Date _ <br />FA# <br />H S'7 6______ <br />c. f f 6 ki p • > -FT-