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11, To be completed bv applicant <br />Lie. Plata # <br />1 <br />FA# <br />3. To be co <br />1868 E. Hazelton Avenue | Stockton, California 952051 T 209 468-3420 | F 209 464-0138 <br /> Date .faawatH !xv»n <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />________Bus. Phone <br />Owner/Operato r <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />operator fails to comply with <br />commisaary 0wner^K3|£ptiQ <br />Signature <br />I www.sjgov.org/ehd <br />kareem.mohsen@ochealth.org (925) 608-5533 <br />SANJOAOUIN <br />-----COUNTY— <br />teJkrgquiaL <br />State Zip <br />Environmental Health Department - <br />COMMISSARY AGREEMENT ^3<’'Z‘ <br />Mobile Food Facility ♦ Caterer <br />land 2 # your commissary it tocat^d outside of S*n Jo^uin (k>unfy ^90 compi^ ^cik^ <br />1 <br />Ruainass Mafne_H4» Htwnfimn gfruMa kwOwnadOparatorNameM*. <br />Business Mailing Address. <br />Qty State Zip Bus. Ph. AH. Ph. <br />t Martha iwyyiMH _ hereby state that the above information is current, true and correct to <br />toe best of my knowledge and agree to utilize my approved commissary in accordance with California Health A e <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary « discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties <br />Signature. <br /> Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br /> Vehidewash <br />---------' ^Htom^tion I have provided is current, true and <br />inions of this agreement, or if this agreement is modified or cancettecrtoe <br />^ediately <br />-----------------Date _ <br />llNVLHf^TH^-------------------of San Joaquin Co. <br />Th. commawry K located in Cowra Costa n <br />conmmwry requirements in ciitanl. H^lth & MMy Cod. Th. <br />AovconmiM.y. PImw notify EHD if the .tetu. of th.lr op^tino ” •v«w* * <br />REH8 Sior»tur.v^?4ga^>t, -------Data 08/05/25 ’ <br />Commissary Name <br />Address. ?17<l Martin -9t <br />C’bLBjttSbuqj______________ZlpjM565___ <br />Check all appropriate services provided: <br />Q Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />t StrfG -sfiMMaL <br />correct to th. best of my knowtedge, and meets the California Health & Safety Code reqUrem^rts~ If tte tod fedi^ <br />nnamtrtfW fail* tft rt/wnnlw tAfkh Hsa nJ thia ur aa_:_ _________. . __ • <br />El <br />•'V sZ- O.\ <br /><' r-xp A <br />\ / <br />Greotness growi here. <br />REC’D <br />AUS 04 2025 COMMISS,