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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 />Lie. Plate# <br />Alt Ph. <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 />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 />Electrical hook-ups <br />Toilet and handwashing <br />S Potable water <br />O Vehicle wash <br />FMt____________________ <br />SAN JOAQUIN <br />------COUNTY------ <br />Grectnc'ss qrov/? r-ers. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />1. To be completed by APPLICANT__________ _ <br />Business Name_ |\ AO I Ce- _____________ <br />Owner/Operator Name K ~ <br />Business Mailing Address S *S \T^- V~AtJ 0 U <br />City StateCA Zip Bus. 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_peqalties. <br />Signature <br />3 <br />H GJ r 2*^ o K> 5 m - <br />Ssc <br />2?n <br />c <br />7. <br />pS 3 <br />- <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name. P I C K g 67 <br />Address 3^//^ zb zw /A fr Bus. Phone <br />Citv CJG ^/tZ Zip Owner/Operator <br />Check all appropriate services provided: <br />O Wastewater disposal D 3-compartment sink <br />Q Solid waste disposal O Food preparation <br /> Hot & Cold water for cleaning Store refrigerated food <br /> Store dry food/supplies ^O^Overnight parking <br />I,, hereby state that the information I have provided is current, true and <br />correct to the best 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 atu re <br />6 be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />2 <br />c <br />Q m <br />> <br />gm <br />Ot