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Environmental Health Department <br />Date <br />REHS Signature Date <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SANJOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />FA# <br />W 2G? <br />| 2. To be completed by COMMISSARY OWNER/OPERATQR <br />Commissary Name <br />Address ^<^3/ <br />City <br />___________ <br />_________Bus. Phone <br />Qwner/Operator <br />Or" <br />Zip <br />Check all appropriate services provided: <br /> 3-compartment sink □Electrical hook-ups <br />Q^Fdod preparation oilet and handwashing <br /> Store refrigerated food CzFotable water <br />EdHDvemight parking ^xA/ehicle wash <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 />operator fails to comply^vith the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner sh^fFnotifyihe EHD immediately.Sign.atdre^Z^^X' -Date <3.3 <br />3. To be qdfnpleted 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 />Wastewater disposal <br />X\?olid waste disposal <br />O Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, 7^^ _________ <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 />Business Name <br />Owner/Operator Name VWAK <br />Business Mailing Address (14 <br />City ^iVliDCi^A^gtate^ Zip^l Bus. Ph.^^C Alt. Ph. <br />I, AY t 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 <br />Lie. Plate # ^C\/