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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 <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 />M Electrical hook-ups <br />y Toilet and handwashing <br />J>4 Potable water <br />Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />L (A <br />F as j <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 />Lie. Plate# <br />I.Tobe completed by APPLICANT_______ <br />Business Name_ 7^- <br />Owner/Operater Na me /\ Ay’ <br />Business Mailing Address // <br />City^W1-^^ \ , Stated Zip Bus. Alt. Ph. <br />I, JPiA/If 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 p§"‘,x!‘* ” /? ' <br />Signature . Date S~~ <br />: SAN.JOAOUIN <br />COUNTY <br />Greotnes' urows hci <br />Wastewater disposal <br />E( Solid waste disposal <br />O' Hot & Cold water for cleaning <br /> Store dry food/supplies • <br />I, <br />correct to the best of my knowledge, an- <br />operator fail st© comply with the coAd <br />commissajyow^er shall notifytl^e'EHD immediately. <br />Signaturp „ <- <- <br />~~U s 7 <br />2. To be completed by COMMISSARY QWNER/QPERATOR <br />CommissaryName L Co TG 0 0-1 FA# <br />Address ^9 00 F as H (a<( L Bus. Phone (ZC 4 "" S 5 TQ <br />City Vk/n Zip 9S CO 7 Owner/Operator G?), CH/p /IrC <br />Check all appropriate services provided: <br />3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Overnight parking <br />2, hereby state that the information I have provided is current, true and <br />Uneets the California Health & Safety Code requirements. If the food facility <br />fions of this agreement, or if this agreement is modified or cancelled, the