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here.REC El' <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date <br />Date <br />DateREHS Signature. <br />£PEIectrical hook-ups <br /> Toilet and handwashing <br />IZ Potable water <br /> Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />MAY 14 2024 <br />STANISLAUS COUNTY <br />DEPT OF ENVIRONMENTAL RESOURCES <br />- . —1 <br />Environmental Health Department <br />Lie. Plate # <br />EJ-S-compartment sink <br />CF Food preparation <br />P2 Store refrigerated food <br />pT 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 />S ig n atu re <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 6 WS ______County. The above food facility meets the <br />commissary requirements in California Health & Safety Cod J. The above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />|\AcC2Cuy^Date ^7 2^- <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Commissary Name FA# ‘ <br />Address ‘PPdnxb _______________Bus. Phone l"7z<^> <br />City ZiP Owner/Qperator CCO- <br />Check all appropriate services provided: <br /> Wastewater disposal <br />d Solid waste disposal <br />ET Hot & Cold water for cleaning <br />JXStore dry food/supplies <br />i, —___________ <br />&j <br />67 <br />1. To be completed by APPLICANT <br />Business Name fy-'-ft.- <br />Owner/Operator Name <br />Business Mailing Address <br />Statefe/ Zip Bus. Ph.Alt. 3 <br />i, '7aJ/‘3 ______, 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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />\ir\ (YUc^X <br />tCtSllTjOAOUIN <br />. fi^UNTY