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Environmental Health Department <br />REHS Signature Date <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehcl <br />_FA# <br />SAN JOAQUIN <br />- C O U N T Y <br />CCa <br /> Bus. Phone <br />Owner/Operator (A <br />Electrical hook-ups <br />/^- Toilet and handwashing <br />7^ Potable water <br />Vehicle wash <br />Date I P <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 />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 />1. To be completed by APPLICANT <br />Business Name Q JJc. Plate # g'3 <br />Owner/Operator Name^/Cj JS <br />Business Mailing Address ff^Sl /V OZ <br />City StatecYT-Zip Bus- Ph-___________________Alt- Ph. <br />i--------------------------------------------------------------, 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. / f <br />Signature (/■ Date <br />2. To be completed by CQMMISSARYoWNER/OPERATQR ~ | <br />Commissary Name_ <br />Address LP7Q <br />City i Q\k Zip qstmO <br />Check all appropriate services provided: <br />p Wastewater disposal 3-compartment sink <br />Solid waste disposal Food preparation <br />Z* Hot & Cold water for cleaning □ Store refrigerated food <br />Store dry food/supplies Overnight parking <br />i. _, 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 notijy the EHD immediately. <br />Signature