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Environmental Health Department <br />Lie. Plate# ^7 5 j ( <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 />tposm -gqiz=«- <br />SANJOAOUIN <br />------COUNTY------- <br />k i/loj <br />X 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />X Overnight parking <br />X Electrical hook-ups <br />X Toilet and handwashing <br />Potable water <br />Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />, and meets the California Health & Safety Code requirements. If the food facility <br />conditions of this agreement, or if this agreement is modified or cancelled, the <br />yjiediately. <br />_____________________Date___3 / X'/T/o <br />3. To be completed by thedEMTHEALTH 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 />- <br />Commissary Name 4 <br />Address X/ i ij/ <br />city zip <br />Check all appropriate services provided: <br />X Wastewater disposal <br />Solid waste disposal <br />'X H°t & Cold water for cleaning <br />O Store dry food/supplies <br />I, hfas'Z. <br />correct to the best ofmy knowledge, <br />operator fails to comply with ttfe cc <br />commissary owner shall notify thp EHp-jni <br />Signature <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 />,1. To be completed by APPLICANT ________ <br />Business Name MeKiCOjA <br />Own e r/O pe rato r N a me RQSq 4- <br />Business Mailing Address PoBo X <br />City Gna|-^-State QA Zip 4 Bus. Ph.26%j ?-/ '4 S 7 O 5 Alt. Ph/Zfo/A 2S j 2S | g <br />----------------------------- -> 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 •Date 5I/CII <br />2. To be completed by COMMISSARY OWNER/OPERATOR ~| <br />_____fa#__________________ <br />Vr_________________.Bus. Phone_ [wcfl s'?? <br />Own e r/O pe rato r_ rsfr/