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Environmental Health Department <br />Complete sections i eno'2. If your commissary is located outside of San Joaquin County also complete section 3. <br />z <br />Date <br />Date REHS Signature <br />•Sj Electrical hook-ups <br />sj Toilet and handwashing <br />Potable water <br />Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility --*■ Caterer <br />SAN JOAQUIN <br />------COUNTY------ <br />■1868 E. Hazelton Avenue [ Stockton, California 95205 | T 209 438-3420 j " 209 464-0138 | www.sjgov.org/ehd <br />1^25 C0Z3H <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />GT 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 notityJhe-EHQ^mediatety. / <br />Signature Date ] 174 <br />3. To be completed by the ENV HEX-: nsdiction outside or Joaquin Co. ' <br />The commissary is located in _________ ____County. 1 he 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 Name_ l'17s <br />Address TO <br />City <7 Vv rt <br />•j. To ce completed by .APPLiCAN'T <br />Business lT I <br />Owner/Operstor Name Vj o "S A1A OU.Qty,_____ <br />Business Mailing Address *3^0(0 <br />CityStdCkVrr.rt StatefA Zip^9 0G Bus. Ph.Q.OQ-T Alt. <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. <br />Signature^VVAnTr) __________________________ Date^S . <br />2. To be completed by COMMISSAR .■ ~ . P/OPERATOR <br />d,, /LfrpgvrA Bus. Phone / <br />Zip G Owner/Operator 52^ <br />Check all appropriate services provided: <br />gp Wastewater disposal <br />Solid waste disposal <br />I?" Hot & Cold water for cleaning <br />X’ Store dry food/supplies <br />I, jg <br />Lie. Plate #