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Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate# <br />Date <br />coirect to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />Date <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 />ODO 4^ <br /> Electrical hook-ups <br />Toilet and handwashing <br />Ji. Potable water <br /> Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Wastewater disposal <br />Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />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/me EHB-immediatjIy. / <br />Signature Date--------- <br />■3; To be compieted~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 />SAN JOAQUIN <br />COUNTY <br />Greotness grows here. <br />2. To be completed by COMMISSARY QWNER/QPERATOR______ <br />Commissary Name. <br />Address ft //(^4 Bus. Phone <br />city ///iV7?zy^ Zip Owner/Operator <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 />JE To be completed by APPLICANT __________ <br />Business Name Jr//7^ FyC/j'l'_________________ <br />Owner/Operator Name 1 Zjlnh/V <br />Business Mailing Address 5?/^?fo ? O/\ \/- <br />City Moin {■CS'Z'i Stated";# Zip Bus. Ph. ^35^- 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 />commissaiy is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature