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Environmental Health Department <br />Z-3-2^Date <br />REHS Signature Date <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 />Zz'Toilet and handwashing <br />SZPotable water <br />^Vehicle wash <br />FA# ____________ __ <br />(WAYy34-'2.S'?-3 <br />Lie. Plate# Hu) <br />SAN JOAQUIN <br />------COUNTY------ <br />ureofness <jro!*5 <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 />11. To be completed by APPLICANT <br />Business Name i\A -c vr o i "V C u> \ <br />Owner/Operator Name y < U c, w> ckc ~ <br />Business Mailing Address <br />City^^'^-^Statecrj Zip Bus. ph -^^Alt Ph. t <br />C' . hereby state that the above information is current, true and correct to <br />me 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 />revorationranddiSCO?tinUed’ 016 H6™1 b01^mUSt EHD’ FailUret0 nOtify th'® Office may resu,t in permit <br />Signature, _4u^u_7 Date _______________ <br />ISfo be ^plete^ by WMMI^ARY WNER^ERAWR <br />Commissary Name €1 (?6llL0 <br />Address 3SS K). C>U\\A Bus. Phone <br />City LdA\Zip 2.H 0 _Owner/Operator <br />Check all appropriate services provided: <br />^Wastewater disposal <br />[S'/Solid waste disposal <br />i^Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I,________________________________________________________________________________________,<» W..C11U, Uuc cuiu <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />3/3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />^Overnight parking <br />, hereby state that the information I have provided is current, true and <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 EF|D immediately. <br />Signature ...Z~ / <br />3. To be completed by th^N^ HEALTH junsdidtion duteide of Shn joiqtiiiii 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.