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Environmental Health Department <br />Date <br />Date <br />REHS Signature Date <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />Signature <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <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 /> <br />1. To be completed by APPLICANT • <br />■ ' <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />?625C0l^T- <br />' 03 - _______ <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 /> g" OR- ZA <br />2. To be completed by COMMISSARY OWNER/QPERATOR <br />Corp ■ <br />_Bus. Phone <br />Owner/Operator C VMp <br />■ SAN JOAQUIN <br />------COUNTY- <br />G r e o i u t .■ s uro w - h < , <br />3-compartment sink <br />£ .i Food preparation <br />O Store refrigerated food <br />Overnight parking <br />____, hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />Qo I <br />£ • u ya (j {jjcjy <br />__Zip clS'2OS ' <br />FA# <br />G > ' C Vvo H <br />Commissary Name cA <br />Address X 0 C) <br />City ShcMovA <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />J4 Hot & Cold water for cleaning <br /> Store dry food/supplies <br />•> c n uS <br />J <br />Business Name Tpr^' Pr/XG', /M 0 PcTjZ Lie. Plate # V t/ 2-7 to fc1 <br />Owner/Operator Name va b C \ VAu y T 7 <br />Business Mailing Address IM 2Q [5 > <br />City Stated A-Zip cf 52oSBus. Ph.(ppg) l -r&ZSAIt. Ph. <br />i ^*4-1 /AcXirYt > 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. <br />Sig nature 1 \CXYvloe^ V V f9 7