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Environmental Health Department <br />9r <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name Lie. Plate # <br />Date <br />Date REHS Signature <br />□Electrical hook-ups <br />zTroilet and handwashing <br />□Tpotable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />SANJOAOUIN <br />-----COUNTY <br />Greatness grows here. <br />• ■ 1 <br />ry o^yaer shall notify the EHD immediately. <br />— Date <br /> | 3. To be completed^,jhe^ENy^Hl£MWjurisdiction 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 /> 3-compartment sink <br /> Food preparation <br />S^tore refrigerated food <br />□^Overnight parking [^Vehicle wash <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 o <br />Signature * - <br />1. To be completed by APPLICANT <br />Owner/Operator Name _________________________ <br />Business Mailing Address Z/O/? <br /> //SCCfl^lateQAZiD ^CgfyBus. Ph^3g Ph. <br />I. A C | y/-fi-FA-—-_, 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. k i <br />Signature oEzC- <br />2. To be completedTy COMMISSARY OWNER/OPERATOR _____ <br />Commissary <br />Address_ IM3,U ' € _Bus. Phone <br />City Zip Owner/Opefatoit QA- G <br />Check all appropriate services provided:^ <br /> Wastewater disposal <br /> Solid waste disposal <br />□Eot & Cold water for cleaning <br /> Store dry food/supplies