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Environmental Health Department <br />J <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 />3H3toy 2,Lie. Plate# <br />1 - 2-^-Date <br />St he best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />modified or cancelled, the <br />Date <br />Date REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />pQ_Wastewater disposal <br />zQ^Solid waste disposal <br />ctf+lot & Cold water for cleaning <br /> Store dry food/supplies <br />I, <br />correcttothe be <br />operator fails to comply with the conditions of this agreement, or if this agreement is <br />commissary owner sf^all notify the EHD immediately. <br />Signature. <br />3. To be completed 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 />BusinessName <br />Owner/Operator Name A\£redo <br />Business Mailing Address 5 S Cr* <br />City State CftZip Bus. Ph.Alt. Ph. ^0^-7 <2- 0 <br />I, j -■ 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 Envhjonmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the permit h^efer must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />S i g n atu re. <br />2. To-be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Co flA dp < p----------------------------------------- <br />Address 9-^00 Bus. Phone _______________ <br />City Zip Owner/Operator dk; [Q * <br />Check all appropriate services provided: <br />j^LTcompartment sink JS^Llectrical hook-ups <br /> Food preparation Q^Toilet and handwashing <br /> Store refrigerated food Potable water <br />^iOvernight parking X. Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />I vS <br />. -■ v <br />y ;.= Od'" <br />SANJOAOUIN <br />------COUNTY*--- <br />Greo/uess epov/s