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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 />1. To be completed by APPLICANT <br />Date <br />2. To be compieted by COMMISSARY OWNER/OPERATOR <br />Date <br />REHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />J3L3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />S^i-Overnight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />COUNTY <br />Gre.jfn grow <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 />Electrical hook-ups <br />Toilet and handwashing <br />^S^Potable water <br />Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />(1 (X po rcJpZJW FA#_______________________ <br />Bus. Phone 26Q- <br />O wn e r/O p e ra to r 1?-. tt6Vvtp,> <br />Business Name Lie. Plate # ^ U 0 & <br />Owner/Operator Name jOCvy-Cuv-r'C <br />Business Mailing Address 2 E • Po <br />City stat^LL^Zip P? Bus. Ph.Alt. Ph. 20^ 30Z <br />I. A/S AnAcruC '•krTCircX^z. ’Novc^ereby 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 discontinuedUpe permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties^z^C? <br />Signature <br />l> -----------------—■ - - • ■.—■----------------------------=»-------------------- ----------------------------------------■------------------ <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 />Signature <br />Commissary Name L_ tx <br />Address <br />City SHckTcHn Zip 5S2QS <br />Check all appropriate services provided: <br />cfJ^Wastewater disposal <br />Solid waste disposal <br />^JXHot & Cold water for cleaning <br /> Store d/y food/supplies <br />KG 6 K \