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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 />Business Name <br />I <br />nalties. <br />Signature. <br />FA# <br />7-.7^/5'Date <br />3. To be completed by tho^ENV HEALTH jurisdiction outside of San Joaquin Co. <br />Date REHS Signature. <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 />^3-compartment sink <br /> Food preparation <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />■ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />-COUNTY- <br />-,^7 <br />Overnight parking <br />Hot & Cold water for cleaning Store refrigerated food <br /> Store dry food/supplies <br />I,_____ _______________ <br />¥ „ <br />30 3 M <br />1. To be completed by APPLICANT | <br />Cxd> Lie. Plate# M\/AH ^3 <br />Owner/Operator Name <br />Business Mailing Address ____________________ <br />City 3(9(41 StatZ 4 Zip^S/^L Bus. Ph. Alt. Ph. 6 CO^ <br />i. "U <T _ 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 pcjrrpit hpjder must notify the EHD. Failure to notify this office may result in permit <br />revocation a <br />Electrical hook-ups <br />J3 Toilet and handwashing <br />Potable water <br />^Vehicle wash <br /> ___________________, hereby state that the information I have provided is current, true and <br />correctto'thefiest 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 shajTnotify tire EHD^mpnedlately. <br />S ig n at u re______ <br />2. To be completed by COMMISSARY OWNER/OPERATQR <br />?rr A A'// / Bus. Phone <br />C ity ZXj Zi p X Qwn er/Operator <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal