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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 />Business Name <br />Date <br /> Vehicle wash <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 />^(2. '2^03'21^’0 <br />Jfl Electrical hook-ups <br />0 Toilet and handwashing <br /> Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />____L .. <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 />City <br />Check all appropriate services provided: <br />Wastewater disposal <br />JZ Solid waste disposal <br />Hot & Cold water for cleaning <br />0 Store dry food/supplies <br />SANJOAOUIN <br />-COUNTY— <br />Greatness grows here. <br />i. <br />correct to the best of my knowle^a <br />operator fails to comply wrthtiw <br />commissary own^shal/notif^th^t <br />Signature <br />3-compartment sink <br />0 Food preparation <br />Store refrigerated food <br /> Overnight parking <br />, hereby state that the information I have provided is current, true and <br />, and meets the California Health & Safety Codd requirements. If the food facility <br />^fTdifibns of fWs^agreement, or if this agreement is modified or cancelled, the <br />zHD immediately. ) z /A c - <br />Owner/Operator Name <br />Business Mailing Address <br />City StatZ4-Zip Bus.Pk{SY <br /> <br />I,0^1^) (/J / 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. \ [)l / <br />Signature b) Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name_ FA# <br /> Address /V ^ol~F^ Gh __Bus. Phone <br />zip Owner/Operator an/ A - <br />T To be completed by APPLICANT <br /> <br />10 I (aJ i a \j/c^ J