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Er Wastewater disposal <br />Solid waste disposal <br />ViHot & Cold water for cleaning <br />Store dry food/supplies <br />City 71/41,4C6,-, Zip 9S-2. cc- <br />Check all appropriate services provided: <br />• %. <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facil a x <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, tg- <br />commissary owner shall notify the EHD immediately. h.) rn <br />!! , <br />'96,hvon. <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />iirOvernight parking <br />, hereby state that the information I have provided is current, true a <br />Owner/Operator ge1/4k-to..w- <br />cn <br />0 fl` <br />"Toilet and handwashing 0 IV - <br />X m <br />Potable water —I • ( <br />0 <br />O Vehicle wash <br />m • r <br />( • <br />'Electrical hook-ups <br />Oar <br />SAN,JOAQUIN <br />COUNTY <br />Greatness grows hen- <br />1120529P1-+ <br />Environmental Health Department <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 />To be completed by APPLICANT <br />Business Name Cl Q41C Cremm., Lic. Plate # 3C7t 6 & <br />Owner/Operator Name (9,-C Ca cz .44q <br />Business Mailing Address 1 2 (ir— <br />City C1--ock-1-0, State cA Zip grze-r Bus. Ph.(2060 92-3 --v zoe Alt. Ph. <br />I, Cf (Lie (aeld-: , 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 dis • tinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation an <br />Signature <br /> <br />Date I21 -2-3/2i <br /> <br />To, e cvimpleted by COMMISSARY OWNER/OPERATOR <br /> <br />Commissary Name <br /> <br />FA# <br />oet.- <br /> <br />Address Bus. WtN, CV>t_ Bus. Phone <br /> <br />Signature <br /> <br />Date (1?)i 01 : <br /> <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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd