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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 />Lie. Plate # <br />Date <br />Date <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 />B^EIectrical hook-ups <br />S^Toilet and handwashing <br />D^Potable water <br />^-Vehicle wash <br />^4060^37^ <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1. To be completed by APPLICANT <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. <br />SANJOAQUIN <br />10 LkW? ------COUNTY------- <br />Greotness grows here. <br />Ca 3-compartment sink <br />H^Pocd preparation <br />H^Store refrigerated food <br />Overnight parking <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 stja^ notify theJEHD immediately. <br />Signature. <br />Business Name <br />Owner/Operator Name.______ ________________________________________________________________ <br />Business Mailing Address lock-borifle courf' <br />City State C4 Zip Bus. Ph. (^0^)-^^-3113 Alt. Ph. <br />I, ^env)gjt~~, 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, thepermiLh^lder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penajti^s.^^^^^-^^ <br />Signature Date Q f <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name C FA# <br />Address\\Q "oV_________Bus. Phone 2_o9- <br />City ‘b VoCA-orx Zip QSTjo?Owner/Operator <br />Check all appropriate services provided: <br />0^Wastewater disposal <br />Solid waste disposal <br />eKHot & Cold water for cleaning <br />ffl'Store dry food/supplies <br />I, oA