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Environmental Health Department <br /><s. <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate # <br />/O'/b-2SDate <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Date <br />Date REHS Signature <br />, 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 an^pen^ttii <br />Signature <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />COUNTY <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />i ; Food preparation <br /> Store refrigerated food <br />Overnight parking <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 />^<<Electrical hook-ups <br />^KToilet and handwashing <br />^^Potable water <br />^^-Vehicle wash <br /> , hereby state that the information I have provided is current, true and <br />correct to^e 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 shajkrfotify the EHD immediately. <br />Signature 7 Date —---------------------------— <br />Commissary Name Lex <br />Address £> <br />FA# <br />1. To be completed by APPLICANT <br />Business Name __LcsJb <br />Owner/OperatorName L ___________ <br />Business Mailing Address ‘S’bH CisfXx <br />City StateQ^Zip Bus. Ph. -57(9-Alt Ph. 'Zo <br />i, t <br />vFurcUrxij \________Bus. Phone <br />City Zip ZQ Owner/Operator < <br />Check all appropriate services provided: <br />Wastewater disposal df^B'-compartment sink <br />cEf'~Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I,