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tment <br />r <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date <br />Date <br />145 S. KILROY RO <br />TURLOCK CA. 95380 <br />,-S^Electrical hook-ups <br />Toilet and handwashing <br />-Ef^Potable water <br />-0/Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SANJOAOUIN <br />-COUNTY— <br />Greatness grows here. <br />Environmenta Health Dcpar <br />EF3-compartment sink <br />CT Food preparation <br />EK Store refrigerated food <br />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 />R <br />Lie. Plate #_ <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 />REHSSignature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />1. To be completed by APPLICANT ________ <br />Business Name M t elk\ <br />Owner/Operater Name MCl/'iA, ftgcy O <br />Business Mailing Address ^33^ ffc/E <br />City StateCM-Zip 95^5 Bus. Ph 75Alt Ph. 5 <br />i, Peqi Ig/*, 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 ppn^tie; <br />Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR ______ <br />CommissaryName 0[ ((J S>\y 0 to G)rn^'> <br />Address S. Bus. Phone <br />City TL(/1 O Zip_ 95^^ _Own er/O perator <br />Check all appropriate services provided: <br />Wastewater disposal <br />0* Solid waste disposal <br />J3* Hot & Cold water for cleaning <br />0 Store dry food/supplies <br />I. “Bo I <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 <br />,Date g p IQ-2(9^