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r <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 />FA# <br /> Vehicle wash <br />A <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 /> Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br />_________Bus. Phone^________________ <br />Owner/ODerator^^ <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ❖ Caterer <br />SAN JOAQUIN <br />------COUNTY <br />Greatness grows here. <br />3. To tie completed 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 />Commissary Name_ <br />Add ress <br />City <br />Lie. Plate# <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />JZ Overnight parking <br />, hereby state that the information I have provided is current, true and <br />correct to the 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 ownep&h^tTpotify the EHD immediately. <br />Signature <br />Business Name <br />Owner/Operator Name_ <br />Business Mailing Address <br />City StateaW Zip Bus. Ph. 0./)^ Ph.------------------------------ <br />I, , 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. Zl / <br /> Signature_ __________________-_____Date- ; / zr/ ----- <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />PS) <br />zip <br />Check all appropriate services provided: <br /> Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I_____________________________