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� J <br /> SQN• JOQQUIN Environmental Health Department <br /> —COUNTY— <br /> _ .f <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. To be com/ppleted by APPLICANT <br /> Business Name CSG A Plate# <br /> Owner/Operator Name A G6li C <br /> Business Mailin Address 2 r K/to <br /> City tateQ2\Zip ' lXJ Bus. PV-2 2 bj;J Alt. Ph. <br /> I, ,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 a d enaltie's. /J <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Nam vl <br /> Address �J W t 1 Ci Bus. Phone w 2 <br /> City ( p�Owner/Operator Va o <br /> WChe k all appropriate services provided:astewater disposal GY3-compartment sink CKE6ectrical hook-ups <br /> r St�olid waste disposal Food preparation E1'Toilet and handwashing <br /> 9 of& Cold water for cleaning ❑ St re refrigerated food ❑'Po�table water <br /> Store dry food/supplies Ovemight parking G ehide wash <br /> I, , 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 Iy with the conditions of this agreement, gr if this agreement is modified or cancelled, the <br /> commissary o s Ratify t HD' ediately. �-- � I <br /> Signature ( Date -0 & <br /> 3. 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 EMD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/e.hd <br />