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Environments! Health Department <br />Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Date <br />Date REHS Signature. <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 />^3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />^-Overnight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility - Caterer <br />SAN JOAQUIN <br />COUNTY <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 />FA# <br />ll- <br />Secq I c <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />^5 <br />BusinessName_____Tgye_______ <br />Owner/Operator Name 0 V Uc _______ <br />Business Mailing Address <br />City state CT\Zip Bus- Ph- Alt. Ph. <br />I-S>€-Y'~CHO V , 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 /> Signature <br />Electrical hook-ups <br />cs^Toilet and handwashing <br />Potable water <br />(>C\/ehicle wash <br />v. QC M 5 . 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 shall notify the EHD immediately.c. , Z- -> n,Signature_________/ natp <br />Commissary Name Co. Co L <br />Address 2-9.0 0 gjav] <br />City Zip SZoS <br />Check all appropriate services provided: <br />Wastewater disposal <br />j^Solid waste disposal <br />cJXjHot & Cold water for cleaning <br /> Store dry food/supplies <br />I, <br />Cqv pO r-ceU py^ <br />_____Bus. Phone <br />Owner/Operator_ <br />Lie. Plate #_