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Environmental Health Department <br />Date <br />Date <br />REHS Signature Date <br /> Electrical hook-ups <br />jy Toilet and handwashing <br />Potable water <br />Vehicle wash <br />SAN.JOAOUIN <br />-----COUNTY------ <br />Greotness grows here. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />'PS;25<D3?O <br />3. To be completed by the EN\Z 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 />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 />1. To be completed by APPLICANT <br />"TrO \TC3 <br />pt Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i. U 1 <br />correctto <br />operator fails to comply with <br />commissary owner sh^lPrrnjrf' <br />S ig n atu re <br />Business Name LC] ~T)'O [T(a V*) U 5 Lie. Plate # <br />Owner/Operator Name \ M i 0 <br />Business Mailing Address 1^1 Q H c/{/ i C/‘ <br />City S7_0C^ State G^Zip^S3^ Bus. Ph.206/-C>S9-3.5Q Alt. Ph.ZiA L <br />F’- , 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 />Signature A?/Z NUsflfl_________Date HlilzozT <br />I 2. To be completed by COMMISSARY OWNER/OPERATOR <br />7YV(j'C fa#___________________ <br />_____Bus. Phone S^// G <br />Owner/Operator <br />Commissary Name {COrterirtg <br />Address_ 7 7/7 U/Uiq/U 5A _ <br />city. 5 / tiClC "JO Zip S 0 Owner/Operator /\O5 i D <br />Check all appropriate services provided: 0 AJ <br /> 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 />the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />^ccYiditions of this agreement, or if this agreement is modified or cancelled, the <br />H^HD immediately. y /