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Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Alt. Ph. <br />rmit <br />>5Date <br />Owner/Operator <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 />o <br /> Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br /> <br />PsTTo 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 />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />C O U N T Y <br />G''t'ornt’s$ grows here <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName & C^2l^ FA# <br />Address \l // 7 *_________B u s. P h o n e^ <br />City^zT^V Zip^ <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br /> Overnight parking <br /> , hereby state that the information I have provided is current, true and <br />Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <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" 10 )0 <br />| 1. To be completed by APPLICANT <br />Business Name Lie. Plate# <br />Owner/Operator Name A CU yp i d <br />Business Mailing Address ("7 <br />CityT State 6A Zip Bus- Ph^0^)7 ^59^ <br />I, - AL-\J i "H? . 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 Co^nfyf^rivironmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, tha^rmitlhgloer must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />S i g n a tu re____________