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Environmental Health Department <br />Business Name f) <br />Date / —C^L.-S' <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 />Electrical hook-ups <br />Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 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 />SAN JOAQUIN <br />GOONIY <br />13. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin CoT <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 />C\/ Ci o <br />Ue-! <br />FA# <br /> Bus. Phone <br />OvAer/Operator <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. <br />Signature_ <br />Address <br />City CK^ < <br />Check all appropriate services provided: <br />O Wastewater disposal O 3-compartment sink <br /> Solid waste disposal O Food preparation <br />Hot & Cold water for cleaning Store refrigerated food <br /> Store dry food/supplies Overnight parking <br />I. -_ 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 />Z = <br />o m <br />> 7^ <br />> <br />< gm <br />cn <br />1 <br />H £ ? <br />O K3 <br />5 rn <br />Ogc <br />-“2 c n <br />c <br />n <br />3 <br />cn <br />2 <br />G <br />J <br />ver. />7__________Lie. Plate# jy CT ) <br />Owner/Operator Name TTo / A/ A1/1 /) Z _____ <br />Business Mailing Address Lf) <br />State^Z Zip^O J^ Bus. Ph.^^^^-Z^7^ Alt. Ph.2o $ - ) <br />Pfyi) /\RoPx/). 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 pennit <br />revocation and penalties. <br />Signature ‘Date <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name f > C K <~lZ Q & <br />f