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Environmental Health Department <br />Lie. Plate # S I $2.^ 3 <br />Alt. Ph. <br />t \ - oh - i-o'i- rDate <br />A# <br />Owner/Operator <br />//- 5Date <br />DateREHS Signature, <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />145 S. KILROY RD <br />TURLOCK CA. 95380 <br />•0^ 3-compartment sink <br />Food preparation <br />0^Store refrigerated food <br />Ej Overnight parking <br />ST Electrical hook-ups <br />□^Toilet and handwashing <br />Ef Potable water <br />O'' Vehicle wash <br />, hereby state that the information I have provided is current, true and <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 theJEHD immediately. <br />Signature <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 /> //'— -2^5 <br />SAN JOAQUIN <br />-COUNTY— <br />Greatness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />2. To be completed by COMMISSARY OWNER/OPERATOR________ <br />CommissaryName 0 /f(J <2a/Q^ t Co/H/H t F A# <br />Address / Y____________Bus■ ph0ne <br />City Zip Owner/Operator 'Be <br />Check all appropriate services provided: <br />Ef Wastewater disposal <br />Solid waste disposal <br />Sf Hot & Cold water for cleaning <br />Store dry food/supplies <br />i, <br />1. To be completed by APPLICANT <br />Business Name_ ^/ok_ SpoA <br />Owner/OperatorName /\\? <br />Business Mailing Address (S,/, \ > 4, V <br />City States Zip BA? Bus. Ph. Ml-gTZ-St TG <br />I, lYs/wycAyyjo /^Ak/GvTZ, 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