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Environmental Health Department <br />$ f <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />itify the EHD immediately. <br />7016 <br />DateREHS Signature. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />SANJOAOUIN <br />------COUNTY------ <br />Greatness grows here. <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 />Date 04 | <br />ST7) C K7) N Zip 5 ?/) k Owner/Operator [LlK I NT T) P-A b A <br />____________ ______K/1A i-rr " <br />^Electrical hook-ups <br />^Toilet and handwashing <br />D^Potable water <br />KVehicle wash <br />1. To be completed by APPLICANT____________________________________ <br />BusinessNameJKCV-OS TfcCQS CL Lie. Plate# ^.(^6 ^5 <br />Owner/Operator Name V AC IV A IsL. 13 A l^l^-£ <br />Business Mailing Address^^S Pl £ fL AVt~_________________________________ <br />City MANT^LLstateCA Zio^A Wbus. Pt/WAIt Ph.________________ <br />I. y A C N 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 /> <br /> <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name^JNlQlX/_______________ <br />Address j "1 VNI 0 N/ ST Bus. Phone^f)^ ) <br />City_; <br />Check all appropriate services provided: <br />^Wastewater disposal <br />Solid waste disposal yk <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />operator fails to comply with the~conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary own* <br />Signature <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.