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�f <br /> SANJOAQUIN <br /> l�OP t�CO`` Environmental Health Department <br /> —COUNTY— <br /> �r ".I Greatness grows here. <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 /> 1 . T.o.be completed leted b ,APPLICANT. _ c <br /> Business Name H E AVE N L� -DELI C_t1-1 T Lic. Plate# gy 6 55 0,;.�_ <br /> Owner/operator Name as 11Qt <�_ K - e__?n. q'q' <br /> Business Mailing Address Li 1 P\\( E <br /> City aA C-`Y State CA Zip` S Wk Bus. Ph.LO).-'S'l C—I' alAlt. Ph. <br /> I, pts1\4 K K•`-3\ 'A , 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 Date <br /> 2. To be completed 6 .COMMISSARY OWNER/OPERATOR <br /> Commissary Name P 1 C tC (1L�i n e( Cs CIc=A nl FA# <br /> Address 3 u1 I rrrn fJ i R A V t= Bus. Phone ac c1 — gvlp-- <br /> City Seo CK TOA/ Zip rAg SacrOwne /r Operator n <br /> Check all appropriate services provided: O N <br /> n N Z <br /> C3 Wastewater disposal 0 3-compartment sink � Electrical hook-ups X m z <br /> p Solid waste disposal E3 Food preparation Toilet and handwashing 0 333 O <br /> O Hot & Cold water for cleaning � Store refrigerated food E3 Potable water Z n <br /> M <br /> 0 Store dry food/supplies —0 Overnight parking 0 Vehicle wash > D n <br /> I, hereby state that the information I have provided is current,true and G m <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility Cam D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the V' <br /> commissary owner shall notify the EHD immediately. <br /> Signaturem� �Z l r. _' Date <br /> 3. To be completed b 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 Califomia 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.slgov.org/ehd <br />