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Environmental Health Department <br />Lie. Plate6) (£) G? <br />Date <br />Dale REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.ofg/ehd <br />1^3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />pSOvemight parking <br />Commissary Name. <br />Address. <br />City____ <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />----COUNTY------ <br />Greofness aroivs here. <br />^Electrical hook-ups <br />JKF Toilet and handwashing <br />S. Potable water <br />Vehicle wash <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 />FA# <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 />Business Name <br />Owner/Operator Name <br />Business Mailing Address SS '_____ ST ___________ City Stated Zip ^^(2 Bus. Ph/^^G^-^(T AIL Ph. ______________________________________________________ <br />I. VcTSczvxxCy bX<7\o\c,S>, hereby state that the above information is current, true and correct to <br />the bfest 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 />Signature. <br />2. Tobe completed by COMMISSARY OWNER/OPERATOR <br />Eb Ire/fa.----- <br />// Bus. Phone. <br /><//'Zip Owner/Operator <br />Check all appropriate services provided: <br />jaP Wastewater disposal <br />Solid waste disposal <br />IX~Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. ____________ <br /><------i —r , . . <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 irmpediately. <br />Signature <br />______ ' X/Z7 _______.... ____________—-------1 <br />3. To;be completed by the ENv HEALTH jurisdiction outside of San Joaquin Co.J <br />The commissary is located in __ _____County. 3 he 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.