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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 />1. To be completed by APPLICANT <br />Lie. Plate # Q <br />Owner/Operator <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 />Commissary Name. <br />Address <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 />SKElectrical hook-ups <br />Toilet and handwashing <br />££ Potable water <br />Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />FA#____________________ <br />70 <br />si <br />Alt. Ph. <br />Date 5-S> ~ 2.5) <br />SANJOAQUIN <br />COUNTY <br />Greatness gro>vs here. <br />0- Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. ___________ <br />2. Tobe completed by COMMISSARY OWNER/OPERATOR <br /> <br />IHi/e Bus. Phone <br />City ^-0^1 Zip Owner/Operator <br />Check all appropriate services provided: <br />l^'3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />tST 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 shall notify the EHD immediately. <br />Signature_______ <br />^<7 _______________________________________________ <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />Business Name^p7 UTZAb _____ <br />Owner/Operator Name ^K/?T0Jl\e <br />Business Mailing Address 7SCity state Zip Bus. Ph.(^222CM^M <br />I., 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