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Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate#Business Name <br />Owner/Operator Name <br />Date O <br />~7 TJ———— <br />Date <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Commissary Name <br />Address <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ❖ Caterer <br />P Electrical hook-ups <br />P Toilet and handwashing <br />Potable water <br /> Vehicle wash <br />0 3-compartment sink <br />0 Food preparation <br />pF Store refrigerated food <br /> Overnight parking <br /> _________, hereby state that the information I have provided is current, true and <br />■st of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />SAN JOAQUIN <br />------COUNTY------- <br />G > r1 ci t n t's > q -■ o w x < i e r >■?. <br />1. To be completed by APPLICANT_____________ <br />114 a <br />Business Mailing Address "Z,\ 'Z- C, (Tcj S> 4~___________ <br />City |5ie.VoC\ StateZipBus. Ph.Alt. Ph. <br />I,, 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 />Siqnature.kkk-''^ Date Q | ^2. $ <br />2. To be completed by COMMISSARY OWNER/OPERATOR ______________ <br />k j't&f I/m 1^i 1 ___fa# <br />Ic _______Bus. Phone <br />City / GGIG (____________Zip 944^/? Owner/Operator -^7)^ cl k Vt u <br />Check all appropriate services provided: <br />Wastewater disposal <br />iip Solid waste disposal <br />Hot & Cold water for cleaning <br />1S Store dry food/supplies <br />i, <2 ka t/\J I^T <br />correct to the bfest of my knowledge, <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 tkfe EHD immediately <br />Signature <br /> | 3, To be completecf 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 />REHS Signature.