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Environmental Health Department <br />I <br />Date <br />Lie. Plate# %\/3 \3 <br />revocation and penalties^ . <br />Signat <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />•To <br />1*5. rm-’' ’ <br /> Date /-27W <br />| ATobEgompleted by the ENV fdtALTH jurisdxtion outside of San JdaqWCoTj <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 />REHS Signature <br />SilWOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />FA#_______ __________ __ <br />. pz/7/Jg <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Comptetesecr/ons ? and 2. If your commissary Is located outside of San Joaquin County also complete section 3. <br />Business Name Qayw <’ n /> b F7? <br />Owner/Operator Name s <br />Business Mailing Address <br /> <br /> <br />City^-igC^Q' State Ca_Zip_3XaJ^Bus. Ph 7 Alt Ph(j^Jo ■T/ <br /> hereby state that the above information is current, true and correct to <br />Safetv Codrand 9 ^9ree to utilize my approved commissary in accordance with California Health & <br />rnmmi« d ’ h d S P C0U 7 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 />Date /zy a <br />2. To tjc coniDletod by COMMISSARY OWNER/OPERATOR ------------- <br />Commissary Name Et <br />Address----------?// ///rt/ Bus. Phone <br />1 y-------4^Z i p Z yOwner/Operator <br />Check all appropriate services provided: <br />EL Wastewater disposal <br />tJT Solid waste disposal <br />EF Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I._______________________ <br />ET3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Cf Overnight parking <br />--------, hereby state that the information I have provided is current, true and <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled the <br />commissary owner shall notifyrthe EHD immediately. <br />Signature <br />Electrical hook-ups <br />& Toilet and handwashing <br /> Potable water <br />Vehicle wash <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements.^