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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 />3 Lie. PlateBusiness Name <br />1 <br />Date <br />3. To be co <br />Date REHS Signature. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />p^3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />^J&Dvernight parking <br />eted by the ENV HEALTH jurisdiction outside ofSan 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 />City <br />Check all appropriate services provided: <br />^Wastewater disposal <br />BnSolid waste disposal <br />□FHot & Cold water for cleaning <br /> Store dry food/supplies <br />SANJOAOUIN <br />-------COUNTY------ <br />Greatness grows here. <br />s(a v\^<2_________________ <br />l.HZo £ s b__________________________ <br />City State Zip ^$705 Bus. Ph. 7QQ- 50?Alt. Ph. / <br />I, AlT , 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_ Al fl rtf W A <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName TjUC_______FA# <br />Address 3SS KjC Bus. Phone 7-0 i Z S7 3 <br />L~-C>d |Zip C Qwner/Operator .A I V> r r L <br />1. To be completed by APPLICANT <br />TqT' ~j /1f/T6A <br />Owner/Operator Name V\ca v\ <br />Business Mailing Address <br />State <br />Electrical hook-ups <br />jA Toilet and handwashing <br />^O^Potable water <br />^^Vehicle wash <br />I, Coe ✓yAy . hereby state that the information I have provided is current, true and <br />correct to the befet of my knoWledgeTand 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 theJ>ID immediately. <br />Signature <br />Date 5~~