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Environmental Health Department <br />Date <br />REHS Signature. <br />fX Electrical hook-ups <br />y Toilet and handwashing <br />Potable water <br />Vehicle wash <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />SANJOAOUIN <br />GOUN FY <br />C,r. u'-.r .5 . I . <br />a <br />The commissary is located in <br />commissary requirements in C <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements^. If the food facility <br />operator fails to comply with the conditions of this agreement, or i' ■' ' <br />commissary owner shall notify the EHD immediately. <br />Signature 0916 <br /> <br /> <br />To be completed by the ENV^HEALTH jurisdiction outside of San JoaquinQo^J <br />, __________County. The above food facility meets the <br />■ •! 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 /> Date — <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 />Marascos Plate# <br />fg-eA Q on -ga k-S <br />A on i ezL <br />Business Name <br />Owner/Operator Name <br />Business Mailing Address I 0 () <br />City State C A Zip Bus. Ph.J Alt. Ph. 2xuc\ - "O ( -SC <br />|t Chnn-zqks < 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 and penalties.Signature (?/ (s? P'^'i (C ____________________Date-i-------------------- <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR_ ______________ <br />Commissary Name Lg Corrt&r'ci al FA# <br />Address '2°\C)0 Bus- phone --------- <br />City Zip S STEPS' Owner/Operator ‘F1 *' AfcrTe^rF J<2, <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I r\ Z1 K. <br />TJif 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 />if this agreement is modified or cancelled, the