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Date <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Lie. Plate# M sJ$ H It) <br />QTwx/N <br />Environmental Health Department <br />gfl/yastewater disposal <br />10 Solid waste disposal <br />Hpt & Cold water for cleaning <br />Store dry food/supplies <br />_FA# <br />SANJOAQUIN <br />1 / ------COUNTY- <br />Greafneu grows herr. <br /> Date <br /> <br />_2. To be completed by COMMISSARY OWNER/QPFRATOR <br />Commissary Name"7feg^/^/>^y?/'73g.5 ^3 ________f?-“ <br />Address ( 'P)^P4i>U/ Bus. Phone . <br /> Zip Owner/Operator PPjfpi <br />Check all appropriate services provided: <br />3;compartment sink lXElectrical hook-ups <br />Food preparation ET^Joilet and handwashing <br />^tore refrigerated food Potable water <br />1/ Overnight parking S^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 />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled the <br />commissary owner shallnotify theEHD immediately. <br />Signature Date J1/?/ <br /> <br />|_3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. 1 <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 <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 />Business Name 'TV\< FwA "ioo y\__________________ <br />Owner/Operator Name fD flkA KoV, <br />Business Mailing Address CQV/l <br />Cityj^cg*^ fi^State£^_Zip_51SoS_Bus. Ph.fe^l |> Alt Ph. fodpois -1°^ <br />th^? r: °j ' - ----------hereby state that the above information is current, true and correctto <br />SafeN Code and Tan r a9ree‘° 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 />hOlder mUSt n0,ify the EHD FailUre tO notify thiS OffiCe may result in pemit <br />Signature