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SAN jOAOUiN Environmental Health Department <br />Complete sections 7 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name Lie. Plate# <br />L^rA-Owner/Operator Name <br />Date <br /> <br />FA# <br />Owner/Operator <br />'ehicle wash <br />Date <br /> San Joaquin Co. <br />REHS Signature Date <br />'868 E. haze tc- Avenue F 202 464-0'38Stockton. California 25205 T 202 468-3420 <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. The above checked sen/ices are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />Jectrical hook-ups <br />oilet and handwashing <br />’otable water <br />v.h/’.v.s cov.c'c e^c <br />U A'TTY, 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 penaltjA- n * \ <br />Signature <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Business Mailing Address PCA CCT~ <br />City SlT^kTv^state Q^Zip S^C-Bus. Ph A|t Ph <br />i, <br />Commissary Name FA# <br />Address /T .^F Bus. Phone ~7 <br />City Zip Owner/Operator <br />xz c <br />Checicali appropriate services provided: <br />la^rastewater disposal E'S-compartment sink <br />^koolid waste disposal (fjJ^ood preparation <br />^xHoL& Cold water for cleaning (^pStore refrigerated food <br />2?zStore dry food/supplies ^^vemight parking <br />I. 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 canceiled, the <br />commissary o^rrer shall notify the EHD immediately <br />S i g n a t u re________________________________