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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 />JW <br />IPCtXy V vne-t Oft- ZJ-IDate <br />- 0^ - 2-6/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 />jQ Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />E3" Vehicle wash <br />Q-O Q |’ Cl I <br />Owner/Operator <br />Bus. Phone <br />G t 21 <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />gj Wastewater disposal <br />Solid waste disposal <br />fl Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i, ysci Poy nuS. <br />1 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 />FA# <br />3-o'h 0 <br />"CVu'q1^ Ar He. 4+y'2 <br />SAN JOAQUIN <br />— COUNTY----- <br />Ck <br />City StbCKAOxO Zip ^S2OS <br />Check all appropriate services provided: <br />El 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />fl Overnight parking <br />Y\Ci CjS YACxS___________> 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 owner shall notify the EHD immediately. <br />Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name I <br />Address ^-^06 <br />Business Name ^rOY~4~v P<Q~xCa /Xq KLj Lie. Plate # <br />Owner/OperatorName \ b<\-IriVa-c?_______________________________ <br />Business Mailing Address IM 2Q Iz » <br />City cVock-Vrvy Stated A-Zip 5 S^C^Bus. Ph.fooA) c332SAIt. 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 | \ k