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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 />Business Name <br />DateSigna <br />Date <br />Date REHS Signature <br />p Electrical hook-ups <br />P Toilet and handwashing <br />B Potable water <br />I <br /> Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />SANJOAOUIN <br />------COUNTY <br />Greatness grows here. <br />Lie. Plate# Q <br />Z To be completed by COMMISSARY OWNER/OPERATOR__ _______ <br />Commissary Name QwituA <APQu fa# <br />Add ress Bus. Phone <br />city zip Owner/Operator Qo ll\| <br />Check all appropriate services provided: <br />0 Wastewater disposal <br /> Solid waste disposal <br />EhHot & Cold water for cleaning <br />Store dry food/supplies <br />I.____________________________ <br />3-compartment sink <br />|£] Food preparation <br />pT Store refrigerated food <br />B 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 />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 Date 11 I | <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. <br />_________Date t \ | _____________ <br />1. To be completed by APPLICANT___________ <br />¥ » O-vex'v <br />Ownsr/Operator Name )JP<______Vs <br />Business Mailing Address /o^xi /)l/t <br />City S^gcX k A State C^Zip ?6AxABus. Ph. - Qo-^g5^Alt. Ph.?/6 <br />I, ^v/ov\■ 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 discontinuedjtie-permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and p^oatttes?^ <br /> \\ /