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PKosHSfof <br />Environmental Health Departmer <br />1. To be; coi <br />Date <br />REHS Signature <br />T 209 468-3420] F 209 464-0138 | www.sjgov.org/eh <br />Wastewater disposal <br />Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />1868 E. Hazelton Avenue | Stockton, California 95205 | <br />t1’-. ■ ■ <br />Safety Code, <br />comi <br />revocation and penalties. i I <br />Signature— <br />2. To^be <br />ity LffjJ-]ru-iofZ>_____^P- <br />SANJOAOUIN <br />■ COUNTY--- <br />• '<' ; if nrK-. glows here. <br />3. To <br />operator fails to comply with the conditions of this agreement, or <br />commissary ownertshall notice EHD immediately. <br />Signature ------- <br />___FA# CO27 <br />fl r\J- . Bus. Phone_ - 71 a - ytf <br />7 ^'SOOwner/Qperator <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer - <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br /> <br />Business Name, j c/I /^Lic. Plate # HV^S^O. <br /> numor/nperatnrName , AnAI^P. KuCH'&HPr<A <br />Business Mailing Address I (". I K / ...frLGq--------------------1—----------------------------------------------- <br /> City VaN StateC/V Zip V/3) Bus. Ph.^cW V/32^Alt. Ph.4^8 'I' <br />I I NIV H S^PH .Ca- . hereby state that the above information is current, true and correct to <br />the best of my knowledge andVgree to utilize my approved commissary in accordance ^thf <br />Safety Code and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />missary is discontinued the permit holder must nothy the EHD. Failure to notify this office may result in permit <br /> Date // <br />Commissary Name, <br />Address <br />Cil <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />ffi^Ovemight parking <br /> hereby state that the information I have providedis ^e^U®c^t <br />if this agreement is modified or cancelled, th <br /> <br /> Date I !------------- <br /> <br />. , ... County. The above food facility meets th <br />XXZX—in "d services are avaiiadie at W <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />Date______________________________ <br />E^EIectrical hook-ups <br />gAoiletand handwashing <br />Potable water <br />m'Vehicle wash <br />. (X . hereby state that the information I have provided is <br />eland .the CaNform^^ <br />EHD immediately.