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Environmental Health Department <br />Date <br />REHS Signature.Date. <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 1 F 209 464-0138 | www.sjgov.org/ehd <br />FA# <br />2.0^ ^7 S&&) <br />COMMISSARY AGREEMENT <br />Mobile Food Facility * Caterer <br />SAN JOAQUIN <br />......COUNTY...... <br /> Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />Ry) s/f <br />J ___Bus. Phone <br />Owner/Operator <br /> Electrical hook-ups <br />□- Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />hereby state that the information I have provided is current, true and <br />* ' * If the food facility <br />operator fails to^cimfrty with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shaS notify the EHD immediately. <br />Signature ________________Date 7/^'/p£>Z<g <br />13. To b4 completed by the ENV HEALTH jUfisdiction 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 />Or / _______________ <br />Commissary <br />Address <br />City Zip. <br />Check all appropriate services provided: <br /> 3-compartment sink <br />O Food preparation <br /> Sto^e refrigerated food <br />CFovernight parking <br />■r^z hereby state that the information I have provided is <br />correct'to the be^hpf my knowledge, and meets the California Health & Safety Code requirements. <br />c*mf <br />ier sh: <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT ■■ '■V | <br />Business Name Lie. Plate #. <br />Owner/Operator Name <br />Business Mailing Address.. <br /> City'TV^^J Stated Zip ^>377 Bus. Ph.. <br />I, IJ r^lXH^An 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. <br />Signature Date ~ 'tk#