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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 />‘jk Z I 7-CrQLie. Plate # <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 />Y Electrical hook-ups <br />Toilet and handwashing <br />^TPotable water <br />^Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />------COUNTY------ <br />Greolnrts qrow\ heie. <br />QKS-compartment sink <br />Food preparation <br />Y; Store refrigerated food <br />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 />FA# <br />to______ <br />1. To be completed by APPLICANT _____________ <br />Business Name_ /IJ <br />Owner/Operator Name cS* T) fY <br />Business Mailing Address 7 ^~///S Zx/v/ <br />City StateCA-Zip^SA^T6115- Ph- 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.Signature______^7’^- 0ate 3 /^/ __________ <br />2. To be completed by COMMISSARY OWNER/OPERATOR________________ <br />CommissaryNam e | / n * <br />Address !fo . Bus. Phone <br />City Zip Owner/Operator <br />Check all appropriate services provided: <br />jjjr Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Kl Store dry food/supplies <br />I. <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. 7 / <br />Signature Date / Z- <br />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.