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ZVoOOOS | <br />Environmental Health Department <br />ss grov <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date <br />CMrO <br />.nowlet <br />Date <br />Date REHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />__________________) <br />H U W5U <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />------COUNTY— <br />Gre <br />^(3-compartment sink Electrical hook-ups <br />^Food preparation /X Toilet and handwashing <br /> Store refrigerated food Y Potable water <br />□ Overnight parking ^Vehicle wash <br />___, hereby state that the information I have provided is current, true and <br />and meets the California Health & Safety Code requirements. If the food facility <br />^conditions of this agreement, or if this agreement is modified or cancelled, the <br />fiKEHD immediately. . » i <br /> a I it juns <br />3. T^I^Zcompleted 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 />Signature, <br />2. To be completed by COMMISSARY QWNER/OPERATOR_________ ______ <br />Commissary Name\) N \ 0 N C ^-1 N <br />Address S - VMOk _______Bus Phone ^41^ <br />City Zip Owner/Operator T1 <br />Check all appropriate services provided: <br />ON Wastewater disposal <br />TKSolid waste disposal <br />M Hot & Cold water for cleaning <br /> Store dry food/supplies <br />.. YESIK-A S6CA <br />correct to the best oFr^ ’ <br />operator fails to com^ <br />commissary zj^fle^hal <br />Signature <br />1. To be completed by APPLICANT_____________________ <br />Business Name S 0 UV H FftST STREET Gi gJliiate#______, <br />Owner/Operator Name FtllLSTM^ CRANTftA VfltVtr <br />Business Mailing Address. IIM W lOrh >ST <br /> Citv 17.CK-1C InstatecAzp^lS 2/U..S. pr(2Pf) lUiU' ^ZRph*2-^ <br />I, p\/ .X5>"TA,|£- | tjn VONefarby 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 JoaquirUpounty Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued/fWo^fnit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and_o£iialties/Z/y // . | <br />_____