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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 />Date REHS Signature. <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i. <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 />■pe — <br />SANJOAOUIN <br />-----COUNTY------ <br />Greatness grows here <br /> Electrical hook-ups <br />X Toilet and handwashing <br />XI Potable water <br />Vehicle wash <br />1. To be completed by APPLICANT_____ <br />Business Name. V \ N /\ C K—\Lie. Plate # CN\ <br />Owner/OperatorNam e \/ K l\/ P^’f? LV Cl f\!2X.| [k * <br />Business Mailing Address I T F CO P~ V(J C | P— > <br />City\T7X StateL /^\Zip6^ 5747Bus- ph- T-OT' TZH ~7j2-"^fePh. <br />I,, 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. , I , \ <br /> Signature I C-U^Date 11 <9 | | <br />[2^70 be completed by COMMISSARY OWNER/OPERATQR <br />Commissary Name\jNlOM C0N\U\\SS^ TKV CE N TT _ <br />Address. I~|ns- VNION st <br />citvSffiC N <br />_________Bus. Phon/ ~ 5 Ml (/:■ <br />Zip S 'P 6/ Owner/Ooerator p/X I R- C T\ R-/\X)£) <br />Check all appropriate services provided: <br />Wastewater disposal 'V 3-compartment sink <br />y. Solid waste disposal ^fS^Food preparation <br />j Store refrigerated food <br />> Overnight parking <br />PC6 IRE NE , 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 the EHD immediately. \ - <br />Signature, ________________________Date H I C I [ ^2^0-------------- <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.