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■ ■■ <br />^2.-2^Date <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Electrical hook-ups <br />H Toilet and handwashing <br />Potable water <br />£3 Vehicle wash <br />Environmental Health DepartmentSANJOAOUIN <br />------COUNTY— <br />rXj UXOj <br />_____Zip ? C C Owner/Operator Q- ■ . <br />Complete sections 1 and 2. <br />r 1 To be completed by APPLICANT <br />Geeol Ji ess >_• ioa- s h <?■■■: <br />_____________FA# <br />Bus. Phone <br />WtiPh flfenc-H Ip <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />If your commissary is located outside of San Joaquin County also complete section 3. <br />T'j . • F 'V; -:r / <br />Lie. Plate# <br />__(2_ojn,C4. • <br />|;S. Td be completed by the ENV HEALTH jurisdiction outside of San Jbaquin 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 <br />Business Name "7g cos Lo JeffeJx <br />Owner/Qperator Name QisneoS Dez Ven,ce_S <br />Business Mailing Address J Ct son <br />CityJWAi^-------StateCKZip^SLBus. Ph.Alt. Ph. <br /> <br />thT^T1 rv yns - be. r.O-Sb^tate that the above information is current, true and correct to <br />Safet^ my aPPr°Ved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements If the use of the <br />revocationTd Z"' PJrm^Mer muSt the EHD- Fate to notify this office may result in permit <br />Signature-U^V 7^ Date <br />2. To be completed by COMMISSARY OWNER/OPFRATOP <br />Commissary Name <br />Address <br />City Zip <br />Check all appropriate services provided: <br />0^ Wastewater disposal <br />Solid waste disposal <br />ifi^Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, Vxl <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements? IMhe food faJlitv <br />nnprafnr failc tr> r'nmnK/ tkn 4.u:_ ____________± . . ■' <br />or cancelled, the <br />3-compartment sink <br /> Food preparation <br />D Store refrigerated food <br />^Overnight parking <br />--------, hereby state that the information I have provided is current, true and <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified <br />commissary owner shall notify the EHD immediately. <br />S i g n a tu re_____