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Environmental Health Department <br />I <br />Lie. Plate # <br />1 <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <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 />REHS Signature <br />SAN»J<MQUIN <br />-----COUNTY------ <br />Greotness grows here. <br />c FA# <br />Bus. Phone ________ <br />Zip SSLp?- Owner/Operator <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <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 />Business Name Tam iT y <br />OwnerlOperator Name Jo/xr-t Peme? <br />Business Mailing Address ?> C> 2- bg <br /> CityJ>TOC\<Toix/ State CAZipJ^^ Bus. Ph. 2og Alt Ph. fed SST-S-j <br />tir K V 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 />XZmi •' 3an T'H County Environmental Health Department (EHD) requirements. If the use of the <br />“vo^tionlnd penaX ' mUS' EHD' Fai'Ure t0 °ffiCe may result in permit <br /> Si9nature-Date <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address WV) <br />City S \oCmAo<-\ <br />Check all appropriate services provided: <br />g7. Wastewater disposal EU^S-compartment sink <br />li^Solid waste disposal BKfood preparation <br />^^Hot & Cold water for cleaning ES^tore refrigerated food <br />K^tore dry food/supplies ^Overnight parking <br />I, ........................................... <br />°Lmiy kn^ld9e’ a2d meetsJhe Califomia Health & SafetyCode "requirements? If the food facility <br />or cancelled, the <br />y'Electrical hook-ups <br />^Toilet and handwashing <br />'■^Potable water <br />b^Lyehicle wash <br />, hereby state that the information I have provided is current, true and <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified <br />commissary owner shay notify the EHD immediately. <br />Signature