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Environmental Health Department <br />^CC <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd_. <br />Lie. Plate# ^/VlT H 2. <br />V)h t'kn_____________ <br />/S? Electrical hook-ups <br />^PToilet and handwashing <br />Potable water <br />O Vehicle wash <br />bANJUAUUlN <br />-----COUNTY--- <br />nJ/Food preparation <br /> Store refrigerated food <br />O Overnight parking <br />------• hereby state that the information I have provided is current, true and <br />correcUto the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fail^o complrwrjh the conditions of this agreement, or if this agreement is modified or cancelled the <br />commissary ownec^hai^potityjhe EHD immediately. <br />Signaturej-^^^^X^ Date 2/ Il | <br />_3».Tq^^oompletecl 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 />REHS Signature <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />fl. To be completed by APPLICANT <br />Business Name /1 CV) Q A) W H fTKLS <br />Owner/OperatorNamefrAgyx VC^tZiT <br />Business Mailing Address | 2^ CCft <br />City^lOQOTdAj___StateX/LZipgS^J- Bus. Ph. 20$'J 97- f yf?^AIt Ph. <br />, hereby state that the above information is current, true and correct to <br />foe 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 />reOv^ration^ndpeSesUed’the the EHD‘ Failure t0 this office may result in Permit <br /> Signature^ Date <br /> <br />[ 2. To be completed by COMMISSARY OWNER/OPERATOR | <br />— Commissary NameQUt(TAJ QM&lZl/b/lrt 'IWCIC toWlefaa_________________ <br />Address Hll 3 QH/cnQ S'?__________Bus. Phone 20*?~ 2 'Q-/! <br /> <br />city..S~[D C d ‘'O____Zip Owner/Operator ^OS) <br />Check all appropriate services provided: (jj - Ofy <br />Wastewater disposal 3-compartment sink Electrical hook-ups <br /><^) Solid waste disposal <br />/ST Hot & Cold water for cleaning <br />O Store dry food/supplies <br />i. \l SOSiQ-___ <br />correctlto the bestofmy knowledg^and meets the California Health & Safety Code requiremente.'' If the food facility <br />operator fail^ to comply^wi^h f**** < al.:.-----------• .»... j <br />ihal^notitathe EHD immediately.