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Environmental Health Department <br />J <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date <br />Owner/Operator <br />Date <br />Date REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 lwww.sjgov.org/ehd <br />% SAN JOAQUIN <br />------COUNTY------ <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Greatness grows here. <br />0c. <br />F3. 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 />'loysr <br />____________FA#_______________ <br />Bus. Phone_ <br />1. To be completed by APPLICANT <br />Plate# <br />C ' '(9 6 iroQ <br />'^'Wastewater disposal <br />Solid waste disposal <br />gb>Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, S- ______ <br />V <br />2. To be completed by COMM I IS SARY OWNER/OPERATOR <br />Commissary Name_ Co <br />Address SHVX € NViter di\x-____ <br />City Otoc&keA.Zip <br />Check all appropriate services provided: 3 <br />_J GO 0 <br /> 3-compartment sink 'gTEIectrical hook-ups Q S <br />□ Food preparation IgToiletand handwashing Z <br /> Store refrigerated food Potable water O g Q <br />gTJvernight parking Vehicle wash Z q <br />, hereby state that the information I have provided is current, truej^Kjg JP <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food fa^t^ <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, <br />commissary owngx-shajkriotify EHD immediately. O. <br />^nature Date “ S <br />O(A<3f - Ic-eBusiness Name <br />Owner/Operator Name <br />Business Mailing Address /boyy fad4 A er <br />City State Zip^CJlf^ Bus. Ph. -Wc/• 1(^5 Alt. Ph. <br />I, (3>€yr Jg R-/e PC(_, 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 ^eryalti^s. <br />Signature