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Environmental Health Department <br />Lie. Plate# J.E |5|H <br />SV <br />Cc" 4- 20? 5Date <br />Date Signature <br />Date REHS Signature <br />tsf 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />^-Overnight parking <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />SANJOAOUIN <br />------COUNTY------ <br />Greatness grows here. <br />A <br />I 2. To: be completed by COMMISSARY OWNER/OPERATOR <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />|:|iiH!lr^ be completed by APPLICANT ~ OT <br />, 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaq <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 />4S Electrical hook-ups <br />-S Toilet and handwashing <br />[S- Potable water <br />jd 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 owner shall notify the EHD immediately. ■ <br />Z-/ ..Date <br />I o y <br />lU-c. <br />BusinessName_______Los Iu cayo________________ <br />Owner/OperatorNam e______Voy~___________FA rnQ. <br />Business Mailing Address 2.3 <br />City State CP-Zip Bus. Ph.Alt. Ph. 2^- <br />I, Pr \ ’CPU Z-CaYX , 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 per^lties. <br />Signature <br />____________FA#________________________ <br />Bus. Phone -~^S7O <br />Clpt p 1 1 •Ai2,Y\vA4~ <br />Commissary Name Comerci Ci I <br />Address 2.A pO HuvcAmcj UKlv| <br />City Zip ^i s Owner/Operater <br />Check all appropriate services provided: <br />Ej Wastewater disposal <br />S Solid waste disposal <br />P Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I,______