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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 />Date <br />Date REHS Signature_ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 17F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN.J0AQU1N <br />------COUNTY------ <br />Greatness grows here. <br />2 ' -r.' <br /> Zip ^^7/? & <br />Check all appropriate services provided: <br />□^Wastewater disposal <br />Solid waste disposal <br />Gf Hot & Cold water for cleaning <br />Q^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 the EHD immediately. <br />S ig natu re ________________-D ate— )?// ---------- <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 />3-compartment sink ET Electrical hook-ups <br />d/Food preparation Toilet and handwashing <br />Q^tore refrigerated food Potable water <br />£3 Dvernight parking Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />correct to the besFoTrny knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />FA# <br />Lie. Plate# 0055 <br />1. To be completed by APPLICANT <br />Business Name jYVpWd <br />Owner/OperatorName <br />Business Mailing Address_ 16 gA L. <br />City TA.qy\V\ CA State C-ftZip 1 Bus. Ph. 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 />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties.Signature "Date f (O / 0 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address ZzV ^0 S. Cyoa, Bus. Phone <br />City Zip Owner/Operator