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qrows f- <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 />Date REHS Signature <br />Environmental Health Department <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 />' SAN JOAQUIN <br />COUNTY------ <br />Greet <br />O Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />2. To be completed by COMMISSARY QWNER/QPERATOR <br />Tn Ar A/Yr7/fa#___________ <br />_________Bus. Phone. <br />Owner/Operator iC P'AJU 7/ QD <br />Commissary Name. tlk/von P.(A-fen/i <br />Address / 7/ 7 5^ UAJiQU .5/■ <br />city 5>7a f r7r) 47 zip Q SA 0 G <br />Check all appropriate services provided: <br />Wastewater disposal <br />gj Solid waste disposal <br />Xl Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i. C (^5/^i. <br />corre/t to the best of <br />operator fails to corr <br />commissary owner si <br />Signature <br />,Date_ 3 l.pcb <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 />ft to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />y^jffrThe conditions of this agreement, or if this agreement is modified or cancelled, the <br />JIXfptifyAne EHD immediately. / <br /> Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin CoT| <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 TACO V C Lie. Plate# "Z^3 <br />Owner/Operator Name_ <br />Business Mailing Address | 30“3 i fa! <br /> CityTm CCj State CA Zip^s Bus. Ph.2,fl^^ Ph. <br />_, 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 />Sign ature