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Environmental Health Department <br />Date <br />IDate <br />REHS Signature Date <br />J^3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />S^-Overnight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />kJ-..<s . - <br />. <■ - <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 />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 />SANJOAQUIN <br />------COUNTY- <br />Gif'iinPS* 9<ows- <br />Commissary Name__ <br />Address 2-^0 P <br />City SHck-Ecm <br />Electrical hook-ups <br />Toilet and handwashing <br />^i^Potable water <br />Vehicle wash <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 />S i g n a t u re_________y '1^ <br />2. to be completed by COMMISSARY OWNER/OPERATOR <br />O Cl mverct <br />» l4f<rcL (aXc| <br />____Zip <br />Check all appropriate services provided: <br />cgJ^Wastewater disposal <br /><EiJSolid waste disposal <br />^JXHot & Cold water for cleaning <br /> Store dry food/supplies <br />I, <br />Business Name U Lie. Plate # UJ K3 7 <br />Owner/Operator Name PtYvfefvO <br />Business Mailing Address 2 , po 0 <br />City Lvrx Stat^cL^Zip Bus. Ph.Alt. Ph. 20^ <br />I. V^ftvxMfierebv 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,^ permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties <br />Signature <br />Q (V po FA#___________ <br />____Bus. Phone <br />Owner/Operato r