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a <br /> S A N J Q AQ U I N Environmental Health Department <br /> U. COU NTY--- <br /> =�, 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 . To be completed by APPLICANT <br /> Business Name / Lic. Plate# V N 310 S <br /> Owner/Operator Name <br /> Businesp Ma'ling Address /'o'Z <br /> Cit C ` Statell Zip 2007 Bus. Phi Dq—�/DS'-9�g�Alt. Ph. <br /> hereby state that the above information is current, true and correct to <br /> the besi of my knowledge nd 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 pen <br /> Signature Date <br /> 2. To be om leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name4 Ly FA# <br /> Address (Y• Aa Bus. Phone v?0°2.- q& t(- Lt S ?D <br /> City ' , ;-,R0,5_ Owner/Operator <br /> Check all appropriate services provided: <br /> It Wastewater disposal d 3-compartment sink d Electrical hook-ups <br /> M Solid waste disposal [3 Food preparation t6l Toilet and handwashing <br /> till Hot & Cold water for cleaning [3 Store refrigerated food Potable water <br /> E3 S �e dry food/ plies Overnight parking Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the besf of my knowledge„and meets the California Health &Safety Code requirements. If the food facility <br /> operator fail o omply with the- onditions of this agreement, or if this agreement is modified or cancelled, the <br /> commiss owr shall notify e EHD immediate <br /> Signatur �� = Date <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 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.sjgov.org/ehd <br />