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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 />2.7 2 0 ?Date <br />Date <br />Date REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 I T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />O' Electrical hook-ups <br />13 Toilet and handwashing <br />15 Potable water <br />El Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />upphj <br />Bus. Phone <br />Owner/Operator <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 />Lie. Plate # p I <br />SAN JOAQUIN <br />------COUNTY------- <br />Greotness grows here. <br />0 Wastewater disposal <br />0 Solid waste disposal <br />Q Hot & Cold water for cleaning <br />Ej Store dry food/supplies <br />FA# <br />SCI- <br />e. S \Z-y Lx u <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 11 porniu. r6r\nj <br />Addres <br />City Zip C <br />Check all appropriate services provided: <br />Ef 3-compartment sink <br />CJ Food preparation <br />Ijr Store refrigerated food <br />Q Overnight parking <br />I, i O , hereby state that the information I have provided is current, true and <br />correct to thenest of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <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 i g n a t u re D ate-/ / -------------------- <br />1. To be completed by APPLICANT__________ <br />Business Name_ All YAO <br />Owner/Operator Name ~T \^\(XVA <br />Business Mailing Address A^J tUAC) <br />City StateCA' Zip^V/J*^ Bus. Ph. 70*?""?Alt. Ph. <br />I, Zl H k T , 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 ------