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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 />Owner/Operator <br />7/2-l/ZSDate <br />Date REHS Signature <br />0^Electrical hook-ups <br />EJ^Toilet and handwashing <br />0^Potable water <br />H^ehicle wash <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 />□^S-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Overnight parking <br />I, | tVI. 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 ttys agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify'the EHD imjpej&lJely. <br />S i g n a t u re_______ <br />3. To be completed bylhe 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 />1. To be completed by APPLICANT <br />Business Name / dp \ <br />Owner/Operator Name pACClrcAo fat <br />Business Mailing Address WMVvQVnS <br />City state 0* Zip<:<52c5 Bus. Ph. Alt. Ph. 377-0^3 <br />I, Ra CC\ Ctl o , 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 <br />Lie. Plate # 1A/S54A2 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Ad d ress l\j- <br />City LcyU Zip <br />Check all appropriate services provided: <br />0^Wastewater disposal <br />Q^Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />____FA#_____________________ <br />PrVC_____Bus. Phone <br />Date ^7 /Z-/ j