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Complete sections 1 and 2. <br />C^roam <br />REHS Signature.Date <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />I <br /> 3-compartment sink <br />da Food preparation <br />C3 Store refrigerated food <br />Overnight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAOUIN <br />COUNTY <br />FA#______________ <br />Bus. Phone 7. c ei - J? 7 <br />.OwnerZOperator/TV^d^/^ f. <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 />Date nso?/?n?4 <br />Business Namenhanni Ire <br />Owner/Operator Namerh;<n=,n Rqm__________________________________________________ <br />Business Mailing Address 1574 Veteran St <br />Crty- Manteca---------------State_cA_Zip 0^7 Bus. Ph. Alt. Ph. <br />R.am--------------- -------------------------hereby state that the above information is current, true and correct to <br />my knowte<19e and aflree to utilize my approved commissary in accordance with California Health & <br />atety Code, and San Joaquin County Environmental Health Department (EHD) requirements If the use of the <br />re^ti^^d4nalt^Ued 016 P6™* mUSt EHD Fai,Ure t0 nOWy th'S °ffiCe reSUltpermit <br />Signature ( JAgrM-TVM <br />If your commissary is located outside of San Joaquin County also complete section 3. <br /> by APPLICANT ~ ~ I <br />Lie. Plate S (q I _ <br />Environmental Health Department <br />0/c <br />c v <br />-Pit <br />£0. Electrical hook-ups <br />*2 Toilet and handwashing <br />® Potable water <br />Si Vehicle wash <br />hereby state that the information I have provided is current, true and <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />II notify the EHD immediately <br />____________________ Date ____________ <br />Commissary Name C <br />Mdress y <br />City Zip <br />Check all appropriate services provided: <br />Wastewater disposal <br />E3 Solid waste disposal <br />$ Hot & Cold water for cleaning <br />Store dry food/supplies <br />I._________________________________ ____ _ ________ ____ <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements? If the food facility <br />commissary owner shall <br />Signature p 1^/^?.