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Environmental Health Department <br />Date <br />i—r___________ _____________________, ncicuy oiaic utai uic 11 nui11louuii i nave piwviueu ib current, true ana <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />Date <br />REHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />GT**Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Q^ehicle wash <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shah notify the EHQ4mmediately. <br />Signature <br />3. To be completed by thaCfiV 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 />Li r c a r n <. s s q r• S <- ■■._. <br />Bo-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />□z6vernight parking <br />. hereby state that the information I have provided is current, true and <br />FA# <br />Lie. Plate #_ <br />4___________Bus. Phone <br />Owner/Operator <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o 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 />B usiness Name <br />Owner/Operator Name IV Awp T V) <br />Business Mailing Address <br />City J >State ifc Zip S2 A 0 Bus. Ph.Alt. Ph. <br />*■-------f , 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 />Signature Date § I •'2£ <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name (Tl <br />Address_ 5 6 V (A <br />City U>c) \Zip <br />Check all appropriate services provided: <br /> Wastewater disposal <br />Solid waste disposal <br />Q IHot & Cold water for cleaning <br /> Store dry food/supplies <br />i.