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Environmental Health Department <br />Lie. Plate# <br />2 - I Q 'Date <br />to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />-2 -I 0 -Date <br />REHS Signature. <br />t Bus. Phone <br />Owner/Operator <S-> P-i <br />^Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />^Vehicle wash <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SANJOAQUIN <br />COUNTY <br />Greotness ^rows here <br />It <br />l^- <br />Commissary Nam e L. 6K COTi-g./Ci 6.1 C-U <po rof i o <br />Address; 2.^0 0 fc: • <br />city zip 1 <br />Check all appropriate services provided: <br />Wastewater disposal <br />JS( Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. AvkM <br />correcfto th <br />operator fails to comply with the conditions of this agreement, or <br />commissary owner shall notify the EHD immediately. <br />Sig natu re—^2--------------------------- <br />3. To be completed by the ENV HEALTH juris~diction ojHside^SanJoaquin 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 /> Date — <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1, To be compieted by APPLICANT <br />Business Name___ ~Tcxz-k«>^Ui He <br /> Owner/Operator Name *0 6-rc^US <br />Business Mailing Address Pcs^vUj bJ Oykj <br />City Stal'd State Q A Zip ^$2(CI Bus. Ph.Alt. Ph. 7 ^1 <br />I, V (/i (A ■ 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 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Lg (2 QiTr-evCi a I Co<porcchon FA# <br />E . K-aoliTTCj io ay Bus. Phone ^btL- <br />1 c 6hi jj M AR-Hf* 14- <br />IX"3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />TJzJ^pvernight parking <br />, hereby state that the information I have provided is current, true and <br />if this agreement is modified or cancelled, the