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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 />Lie. Plate # <br />g-2-b-^SDate <br />Date <br />Date REHS Signature <br />Commissary Name <br />Ad d re s s O 0 <br />^(3 Electrical hook-ups <br />Toilet and handwashing <br />^j^Potable water <br />Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility « Caterer <br />SAN JOAQUIN <br />COUNTY <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall^fify the EHD immediately. <br /> Signature Date---------2 O' J2X5 L ^5---------- <br />3, To be completecTby the ENV HEALTH jurisdietjonoutside 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 />1868 E Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 1 F 209 4o^-0d38 I mw.sjgov.org ehd <br />1. To be completed by APPUCANT <br />\ i * S k i <br />-Tex 11 Kca y/1 \; <br />I ^3 acecsv <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />__Lex Co m>ercc~Ccl __FA# <br />X/uciq Bus. Phone 2-oR - ^70 <br />City Zip A 5 70S Owner/Qperator G- 6^ p 1 <br />Check all appropriate services provided: <br />^^^Wastewater disposal *r^3-compartment sink <br />$3^ Solid waste disposal U Food preparation <br />f^Udot & Cold water for cleaning LI Store refrigerated food <br /> Store dry food/supplies pk.0vemight parking <br />p , 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 />Business Name_____ <br />Owner/Operator Name I i Kca \/ i \ y\-Ca ' <br />Business Mailing Address | <3^3 Uj <br />City StatedZip A 5^4?^ Bus. Ph. 5 2S " {7/_<?\lt. Ph. <br />I, v\ ft L&A Yx , 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 />S ig n atu re ?