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Environmental Health Department <br />^1256^3Lie. Plate # <br />Date <br />ie EHD immediately. <br />Date REHS Signature. <br />1868 E. Hazelton Avenue |Stockton. California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />P^‘2H0Q2\2 <br /> <br />SAN.JOAOUIN <br />COUNTY <br />, i ., )'. > »v ■. h r < C <br />Wastewater disposal <br />g/ Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i <br />9 5 ^j^OOwner/Qperator <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />ffifovernight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer • <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />H-To be completed by <. <br />Business Name P C/ MOR. E.■ . <br />O wn er/O pe ra to r N a me <br />Business Mailing Address, I 6 0 | <br />City L^TH^OP state Zip 30 Bus. Ph. 7/ Alt. Ph. <br />I, MvRAZ-/ KD7H4 ■ 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 Date<93 | K.j-------------- <br />12. To be compl^-by C0MMISSARY<OWNER7ORERATOR ! T <br />Commissary Name L FA#_& O -----— <br /> Address_ I (^2rJ - Bus. Phone_ <br />City hr of?Zip 9,^ ^j^DOwner/Operator <br />□^Electrical hook-ups <br />Toilet and handwashing <br />[JzKPotable water <br />CTvehicle wash <br />I tS'/'fC Vlr-- kYl^-FL-t-L , 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 ownertshall nobtyttie EHD immediately. y > <br /> ^.nre. - y — Da.e. pp/ZG . <br />3. To^p^fempTeted by the EKife HEALTH jurisdictiQn autside. of SanijJoaquin 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.