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Environmentai Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date <br />0wn e r/O pe rato r fycodkrVoj <br />Date ^y?*-**- <br />REHS Signature.Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0133 | www sjgov.org/ehd <br />CDi^2 <br />SAN JOAQUIN <br />COUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <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 />1. To be completed by APPLICANT______________________________________ <br />Business MucWi'VsrsQ Lie. Plate #_ <br />Owner/Operator Name ~P 0 kp ^4 M Ul.4fi ’V/OP tX?.p~F ( <br />Business Mailing Address m A-'A- viOdl <br />City-SVo^P^ZYO StateQA Zip^S^QS- Bus. Ph,QCA S'33 ?0>iS~ Alt. Ph. <br />11 "(Vo'DACfc.S. A-V■ft/xYT , 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 <br />cf"3-compartment sink <br />EK Food preparation <br />eAStore refrigerated food <br />Overnight parking <br />, hereby state that the information I have provided is current, true and <br />icwledge, and meets the California Health & Safety Code requirements. If the food facility <br />is of this agreement, or if this agreement is modified or cancelled, the <br />yfediately. . j <br />2. To be completed by COMMISSARY OWNER/OPERATOR_________________ <br />CommissaryNam e (AaII) VvgA C>C\ IF A# <br />Address Hi Fl ~TX~iilC-______Bus. Phone <br />City^SWXLTA^O Zip Owner/Operator , <br />QVt\ W Vepr <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />^Vehicle wash <br />VW Hi Fl TXide. <br />zip ASQATj <br />Check all appropriate services provided: <br />gf"Wastewater disposal <br />Ef Solid waste disposal <br />El Hot & Cold water for cleaning <br />Store dry food/supplies <br />I, ~~TV\c>'r>\dx_<\ A.<~ <br />correct to the best of nr <br />operator fails to comply with the conditii <br />commissary owner shaJLjiotlfy the EtJDN <br />Signature