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ft <br />-MUST <br />Date <br />Date <br />DateREHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 lv7ww.sjgov.org/ehd <br />Electrical hook-ups <br />^Toilet and handwashing <br />A? Potable water <br />Vehicle wash <br />Environmental Health Department <br />(\<yV - <br />( € ‘P<\jvn <br />SAN JOAOUIN <br />- - COUNTY----- <br />Lie. Plate# 53> <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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name U X/) 0 A) CA7(~rZ/A/6 C (t/I/ZC/ZFA# <br />Address t3- UAj'QkS ____________Bus. Phone I Co <br />City Sl0nr7?jAl Zip S C? Owner/Qperator I '17fC^C7C> <br />Check all appropriate services provided: <br />JX Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />i. C\ZJi>/V <br />correot to the best of my knowledg <br />operator fails to comply wjttrtHeA <br />commissary owner stjaifnotify th^E <br />Signature <br />JA 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />____, hereby state that the information I have provided is current, true and <br />corredt to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />editions of this agreement, or if this agreement is modified or cancelled, the <br />:HD immediately. / / <br />! 0 / <br />3. To*Se 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 />1. To be completed by APPLICANT_____________ <br />Business Name_ 1=1 C.WrriT) _________ <br />Owner/Operator Name_ <br />Business MailingAddress, chronick ayeCity fifotlCWl StateC.Cl ZiD^S2oSBus. Ph. Ph. <br />I, / ^.L/17 , , 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 discontinuetMhe permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. X/j / / <br />Signature •Date_-■|..Q 1.1 WAS/