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Environmental Health Department <br />ic - 13 -Date> n ? <br />c h. <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. <br />Electrical hook-ups <br />jRf’Toilet and handwashing <br />Potable water <br />^Vehicle wash <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 1 F 209 464-0138 | www.sjgov.org/ehd <br />SANJOAOUIN <br />------COUNTY- <br />Grec• nrrs ht' <br />L.q <br />Lie. Plate # U; b 7 IS±3 <br />: ' pH /C1'’ ; I <br />.py -h-< <br />( y ’I \ <br />■'I ■ <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, fi;v\rA I'kufg/ll/lA <br />o;^» w^indKions-of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shak notify the EHD immediately. <br />S i g n a tu re 3 --------------- <br /> <br />g..:fo be completed by the ENV HEALTH jurisdiction QJtsiqe of San Joagcin 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 /> Date ------------- <br />CommissaryNam e_____|_LX______C c> LX I___________ <br />Address 2>ciOQ £?fi g4- llfay Bus. Phone <br />City Zip <br />Check all appropriate services provided: <br />3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Overnight parking <br />, hereby state that the information I have provided is current, true and <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 /> <br />IWKWQdWXPPLICANT : <br />Business Name r j- i c t P) <br />Owner/Operator Name M dx r > ho)v n <br />Business Mailing Address I H 7^0 Cik 0 P <br />City SVcck'ro^ State C^-Zip C/S2<\ 5 Bus. Ph. ( ZcS J z^Alt. Ph. <br />I, |\A(Av lb e| Vi ■ 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 />B|BteietMW<l<g1OMMISSARY OWiyERMPERATOR <br />FA#_ <br />0wne r/O pe rator »- C h >|j J A iL n Id.