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Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name <br />2. To be ci <br />Vehicle wash <br />REHS Signature Date <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 />Environmental Health Department <br />FA- <br />Electrical hook-ups <br />dTToilet and handwashing <br />Sr Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />u / <br />3. To be completed by the ENV H5EA LT Hi u r is diction outs i d e of San Joa quin Co. <br />City L Z‘P 33/0 Qwner/Operator <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Ilf Overnight parking <br />, hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, arfd meets the California Health & Safety Code requirements. If the food facility <br />Date ) I <br />Date_ //// /7^ <br />SANJOAOUIN <br />------COUNTY------ <br />Greatness grows here. <br />1. To be completed by APPLICANT t <br />Grille J, Lie. Plate # <br /> <br />Owner/Operator Name C <br />BusinesgMailing Address, Vo. -------- <br /> <br />City^^C^?^ State F^gip^F^\F Bus. Ph. ~ Alt. Ph._________________ <br />, hereby state thafthe a^ove information is current, true and correct to <br />the best lif m^knowiedge and agree to utilize mv approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County^fwlrarrfn^tal Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the ||ery(i0iol^r mj^/st notify the EHD. Failure to notify this office may result in permit <br />revocation anefpenalties. <br />Signature <br />•eted by COMMISSARY OWNER/OPERATOR________________ <br />Commissary Name Z-Aplvcp Fg<p<l FA# VO7 ^^3 <br />Address_ A/ 4 /U f^cc/.__________B u s. P h o n e " 7 ! 'T- <br />Zip <br />:e se <br />|j/\/Vastewater disposal <br />B Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i, <br />correct to the best of my knowledge, arid <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner sh^Hj^otify the immediately. <br />Signature