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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 />Lie. Plate# <br />lllfli.rDate <br />Date <br />Date PENS Signature <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 I F 209 464-0138 | www.sjgov.org ehd <br />FR0S4 2345 <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />COUNTY <br />^<fElectrical hook-ups <br />OKToilet and handwashing <br />exJ^Potable water <br />Vehicle wash <br />1. To be completed by APPLICANT <br />£ ctvx ro ■ <br />me. <br />& <br />Up n <br />'Av\x <br />Js^-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />JZfOvernight 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 />2. To be completed by COMMISSARY OWNER/QPERATOR <br />Co YTULrCi cd . <br />tVkvcli vpCvU|______Bus. Phone <br /> Zip_ pf 5 g&JS Owner/Operator <br />Commissary Name_ Lca <br />Address, <br />City <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />i3<Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. J^tA_ Ck <br />operator fails to comply with the"conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shajf notify the EHD immediately. z. .Signature _________ ________-___Date-------! ------------- <br />3?To be completed bythe 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 />Business Name______ <br />Owner/Operator Name <br />Business Mailing Address S u/11 <br />City State OH Zip ^20 S' Bus. Ph.Alt. Ph. ^^0 f YQ <br />I, VAu c Cl 111) , 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 discon|jaded7t^fe permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and pep^Jlies. <br />Signature <br />FA# <br />2,^ - ~lU <br />‘tk p M ftp nei-T