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Environmental Health Departmenta <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 />Business Name <br />Date <br />FA# <br />Date <br />Date REHS Signature <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Electrical hook-ups <br />B Toilet and handwashing <br />/S' Potable water <br />Vehicle wash <br />SAN JOAQUIN <br />-COUNTY- <br />Greotness grows here. <br />Commissary Name_ <br />Address _7O~ <br />El 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />P Overnight parking <br />I,//'//'€.r/y)_____________________- 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 />(1 rv) ( -iz^Lie. Plate # <br />Owner/OperatorName I <br />Business Mailing Address ^6^ Pr - Apt, <br />City State rAZi^;?/T6 Bus. PhVay?/ Alt. Ph. ( <br />I,____________________, 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 'Date /('? / jA ' Z b <br />2. To be completed by COMMISSARY OWNER/OPERATQR <br />__^O /r/yrti^Qc ^/(j.______ <br />//> (ru .' $(/ p Bus. Phone <br />City Zip ^57/#/ Owner/Operato r <br />Check all appropriate services provided: <br />Wastewater disposal <br />p Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <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 />Signature Date_/ (C'________________ <br />3. To be completed by th<Zt W 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.