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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 />Date <br />REHS Signature Date <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 />Owner/Operator Name <br />Business Mailing Address <br />City. <br />I___ <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton. California 95205 | I 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />PiCOSST^ <br />SANJOAOUIN <br />“ ------COUNTY------ <br />Greotn^ts qrov/* hpre. <br />Lie. Plate# 'll Fl <br />1. To be completed by APPLICANT_______ <br />Business Name <br />Niop-MES <br />tW SPf’-iN^ TT <br /> <br />S T7) ( State CA Zip fllpBus- Ph(?T^|p| ? YlfG^lt. Ph. <br />, 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. z 7 <br />Signature Date. <br />2. To be completed by COMMISSARY OWNER/OPERATOR______________ <br />Commissary Name. W10 N CATT/l N6 CD WM M <br />Address. Pin UNION ST Bus. Phone I 5^1^ <br />City C Zip U Owner/Operator <br />Check all appropriate services provided: NICjttT" <br />Wastewater disposal 3-compartment sink Electrical hook-ups <br />S6 Solid waste disposal V Food preparation Toilet and handwashing <br />Yl Hot & Cold water for cleaning yC Store refrigerated food Potable water <br />/Y Store dry food/supplies Y Overnight parking Vehicle wash <br />i. EWflVF Timl _, 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 ov/ter shall notify thepEHD immediately. i .Signature Date ()S / fl G?/7-^ 25 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co.