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Environmental Health Department <br />Complete sections 1 and 2. <br />Date <br />Date <br />REHS Signature Date <br />pjauwv'' <br />operator fails to comply, <br />commissary owner; <br />Signature * <br /><<S^EIectrical hook-ups <br />□"Toilet and handwashing <br />O' Potable water <br /> Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />to complyjMiMhe coryiitions ottfljs agreement, or if this agreement is modified or cancelled, the <br />Amepsfiall notify/the ElflD immediately. <br />_ Date 3 > H I 2- C_________ <br /> <br />I 3. To be 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 /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />ET Overnight parking <br />. hereby state that the information I have provided is current, true and <br />SANJOAOUIN <br />-----COUNT Y------- <br />Greatness grows here. <br />If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />| 1 • To be completed by APPLICANT | <br />Business NameG Llf,Lie. Plate# <br />Owner/OperatorName <br />Business Mailing Address | |^| Q. yj fivC <br />CitylYYxa-Uccx___StateQ Zip Bus. Ph.lcq Zy) Alt 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 />Signature. natfi 2, 1 <br />2. To be completed by COMMISSARY OWNER/OPERATOR ______ <br />pAg, OAjbJS r-K-Q^-.V-A, FA# <br />HZ S-Tlyp^rv B„s Phone ^5- <br />Zip Owner/Operator <br />Commissary Name <br />Address <br />City <br />Check all appropriate services provided: <br />//STWastewater disposal <br />^JZk'Sblid waste disposal <br />/X2 Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. X ____ <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility