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Environmental Health Department <br />I * <br />G <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate # <br />Date <br />Date <br />REHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 lwww.sjgov.org/ehd <br />Stat <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />TPEIectrical hook-ups <br />^f^Toilet and handwashing <br />Potable water <br />Vehicle wash <br />-Ccvc <br />SANJOAOUIN <br />COUNTY <br />C - <br />Wastewater disposal <br />Solid waste disposal <br />-Ef Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, a/Mt: ^=-~ hereby state that the information I have provided is <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. <br />FA# <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name ^-1 C <br />Address Bus- Phone. <br />C j ty Z i p Own e r/O p e r a to r <br />Check all appropriate services provided: <br />3-compartment sink <br />FuTFood preparation <br />L'J Store refrigerated food <br /> Overnight parking <br />a/Mp: ~ . hereby state that the information I have provided is current, true and <br />---------------- - " . . . . . |f 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 EHDimmediately. <br />Signature ------------Dat6-----------------------~----------------- <br />3. To be cor^letedTyTheJIiy HEM.TH 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 /> Date _ <br />1: To be completed by APPLICANT <br /> Business Name_ "/Ta <-G y V g-yxA O s C, <br />Owner/OperatorName______NO G-CpV2. C-YjC-'Z- <br />Business Mailing Address /P <br />City Statd^H Bus. Ph.Alt. Ph. Zerf- <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_p.enalties. <br /> Signature Y Date-/ ~ ^0 " —