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Environmental Health Department <br />Lie. Plate# Business Name <br />Date <br />LLC. <br />Vehicle wash <br />I, <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />GT'Electrical hook-ups <br />EfToilet and handwashing <br />Ef"Potable water <br />Owner/Operator Name___ <br />Business Mailing Address. <br />City <br />i, <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />-COUNTY— <br />GPlf-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 />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 shaJhiotifylhe-EHD immediately. <br /> Signature Date_ <br />_____________________________________________________ < / <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in ‘SAZiaa.iA k 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 , _________Date___sr/14/^___ <br />FA# <br />Bus. Phone -3C&3 <br />Owner/Operator <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 />'tLg <’t <br />ftp I# 5 Ri <br />State Zip Bus. Ph.31 Alt. Ph. <br />I 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 />Signatui€^Date f fl '2~^> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name ffaxS <br />Address /^?// S 5/re <br />City Zip ^$35/ <br />Check all appropriate services provided: <br />[if'Wastewater disposal <br />ET^Solid waste disposal <br />ETHot & Cold water for cleaning <br /> Store dry food/supplies