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f(2. 05^^285 <br />Environmental Health Department <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 />1Date <br />Wk <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <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 />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 />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />(3 Electrical hook-ups <br />0 Toilet and handwashing <br />Q Potable water <br /> Vehicle wash <br />O' Wastewater disposal <br />ET Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies. <br />correct to th^ b <br />SAN JOAQUIN <br />-COUNTY <br />Greatness gro./s A ere. <br />Business Name <br />Owner/OperatorName -S? HA 11 N H <br />Business Mailing Address /J 0^ <br />CityM^bjlAlN MCV^State r^Zip Bus. Ph.^oRg'^^S^ 0 Alt. Ph. D <br />I, li/A*- IN/ S IN H > 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, thej^mit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />S ignatu re_____________ <br />Lie. Plate # <br />2. To be completed by COMMISSARY OWNER/OPERATOR______________ <br />Commissary Name ^CfA# - <br />Address Bus. Phone <br />C i ty ] Zi p / 'p u ( Own e r/O p e r a to r . • <br />Chf^ek all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />□'Overnight parking <br />_____, hereby state that the information I have provided is current, true and <br />correct to th^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 shall notify the EHD immediately. <br />Signatu re_____ i , __________________Date