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PkTobecc <br />y *Date <br />Date- <br />above commissary. Please notify EHD if U <br />R J-1-: R S:nnah ira <br />California 95205 1 T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Wastewater disposal <br />gf Solid waste disposal <br />H Hot & Cold water for cleaning <br /> Store dry food/supplies <br />ta.sanjoaouin <br />------COUNTY— <br />Greatness qrows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, <br />cc<mn/ets s.?cfions 1 and 2. iryour cvnimissary is inched outside of Jo^n Couniy uisu uuinpieie section 3. <br /> <br />e r, ^^.0-2 <br />Environmental Health Department <br />Lie. Plate#. 7/06^7(2 <br />___________ ____________—------------— <br />.57^-^ Ltj _______f ' " A.;- Pn. <br />t< t C]^J feijiwi s/f/ hereby state that the above information is current, true and correct to <br />Co best of my knowf&gZand 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 /> Electrical hook-ups <br />□/Toilet and handwashing <br />ET'potable water <br /> Vehicle wash <br />I > hereby state that the information I have provided is <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. <br />i by ArrLICAN 1 _ <br />'Business Name. . /5S AJ! <br />/ i S'! / t i ' <br />Owner/Operator Nante, <br />Business Mailing Address._/^\<fy/XZ <br />City , /c/ A> State Zri-Z'tM pt <br />/y) f/f / ___________ ____■ heieuy Slate UICII me awwe huviiiicumh io WU.IIW.. <br />the best of my knowidda/and agree to utilize my approved commissary in accordance with <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may resuit in permit <br />revocation and per^lties^^ <br /> Signature’ <br /> <br /> i2. TobTcompietedKy COMMl^Am’ d^NERfePERATOR^._ <br /> <br /> <br />Commissary Nan» 'Z’sS.L—........ ... <br />Addicos - c' / /7c-/Ar-- ■-----*■ ■ ‘........• -- ----------- <br /> City ZjP Owner/Operator J./VH €£... J.. ------------------- <br />Check all appropriate services provided: <br />3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />hereby state that the information I have provided is current, true and <br />’ ; “ ’ ‘ ’ . 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 immediately7 j / , <br /> <br />Sionature ....-------------- <br /> 3. To be completed by the ENVHL^'LfH juri^iiction 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 />Laius of their operating permit changes. <br /> 5