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SAWAAQUIN Environmental Health Department <br /> —COU NTY— <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 leted.by APPLFGANT <br /> Business Name 6�L� UC.Plate# <br /> Owner/Operator Name <br /> Business Mailing Address _ �.9 it <br /> off• <br /> City 1 State Zip USS d&Bus. Ph. �lJr / D Alt h. JS" ��l <br /> I hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to utirize 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 p naltiss. <br /> I <br /> Signature �1(7 �' IJDate.-/ - ._X s «'G <br /> 2 To be;com feted-b COMMISSARY-OV NEWOPERATOR - ..- <br /> Commissary Name <br /> Address Qqg00 E JAW �e Uk Bus. Phone o /14 (0 G1 - Ll 570 <br /> City }U C��CAn Zip �I S ZO S Owner/Operator C.1n l () A C Yl e•4-t <br /> Check all appropriate services provided: <br /> Wastewater disposal E(3 compartment sink El cal hook-ups <br /> olid waste disposal U Food preparation T 'let and handwashing <br /> i�ot&Cold water for cleaning 12 Store refrigerated food ble water <br /> Q rte dry foods pplies Ovemight parking Vehicle wash <br /> hereby state that the information i have provided is current,true and <br /> correct <br /> the my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to complywith the cond "is- of this agreement er-if-this agreement is modified or cancelled, the <br /> commissary?iindrshallnotifytheE immedlately. <br /> Signature :tea- <br /> 3. To completed b the ENV HEALTHjuiisdiction outside ofSan Joa lin Ca. <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 /> REHS Signature Date <br /> 1868 E.Hazelton Avenue I Stockton, Carifoniia 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov org/ehd <br /> P1,0516�ZZ <br />