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Environmental Health Department <br />jfy the EHD immediately. <br />Date <br />i ? -x. v%>F A# <br />Bus. Phone <br />Owner/Operator <br />Business Mailing Add, <br />City_5r>\0Cvc <br />iW» , <br />: SAN.J0A0UIN <br />------C OU NT Y------- <br />Grratn.-is grow. hero. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />s-„i/jom <br />L1JPTe^ompleted by APPLICANT ---------------------------- <br /> BUSineSS Plate # <br /> Owner/Operator , Go ,<■ Cc, <br /> ress_ r.>}e_____________ <br /> ^StateC^Zip gi£iiiBus Ph <br />,he best of the ab0Ve inforrnation is curren‘. ‘rue and correct to <br />Safety Code, and San Joaquin Counti Env ronmlntal H uh accordance with California Health & <br />commissary is discontinued the permit holder must notiMhe EHD^F^'11 (,EHD> re<’uirements- “ ‘he use of the <br />revocation and/pec/altipfl. HD- Failure to notify this office may result in permit <br />Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />---------------------------------- -----------------------------------Date____ <br /> LlTp jfcompleted by COMMISSARY OWNER/OPERATOR <br />Commissary Name c <br />Address \AQ__kL <br /> <br /> Check all appropriate services provided: <br />^„a„a s <br />Hot Cold water for cleaning uYstore refrigerated food Bootable water <br />I SX00"^65 correct to ttebest of my 2?2dedqe'and“mePN thTrnif316 Information 1 have provided is current, true and <br />operator fails to comply with the9conditions of thic ' °mia H.ea h.f& Safety Code requirements. If the food facility <br />commissary ownerthe EHD^ °r * th*S agreement is ™dified - -nceKed, the <br /> <br /> <br />SiSna'Ure-^^--------------------Date/W0< 12026 <br />The commissary is located in n <br /> commissary requirements in California Health j? q f k -----T------uounty- rhe above food facility meets the.pp-coi,.'.,. ■" ■' “ <br />REHS Signature