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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 />ol <br />Alt. Ph. <br />Date <br />jp plies <br />3. To b< <br />Date REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br /> Electrical hook-ups <br /><□ Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Date j <br />)TeTed 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 />SAN JOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />FA# S______________ <br />Pc<.<A,n\Q> <br />•ET'S-compartment sink <br />tTTood preparation <br />□"Store refrigerated food <br />0^Overnight parking <br />\/\ CX . hereby state that the information I have provided is current, true and <br />istbf my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />1. To be completed by APPLICANT________ <br />Business Name 2-^^ <br />Owner/Operator Name. VAac-xe- <br />* <br />Business Mailing Address Ona <br />City S.-VocVA-t>4 State Zip QSadr Bus. Ph. <br />i. Mgica , 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 /> <br />Signature y.//, Date $ / 2- /^/ 2- $ <br />2. To be completed by COMMISSARY OWNER/OPERATOR________________ <br />Commissary Name_ <br />Address, M Pbus. Phone <br />City Zip ^lS~f Owner/Operator <br />Check all appropriate services provided: <br />□^Wastewater disposal <br />Q* Solid waste disposal <br />□"Hot & Cold water for cleaning <br />-□"'Store dry food/su^plies <br />I, <br />correct to the be: <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary pw^er sl^I) notify the EHD immediately. <br />Signature /