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Environmental Health Department <br />Date) <br />Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />DateREHS Signature <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 />Wastewater disposal <br />Solid waste disposal <br />O Hot & Cold water for cleaning <br /> Store dry foe <br />I, <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />supplies <br />o./ ley' <br />SAN JOAOUIN <br />------COUNTY------ <br />Greatness grows here. <br />Lie. Plate <br />Commissary Name <br />Address I I <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />2. To be completed by COMMISSARY OWNER/OPERATOR__________ <br />____________FA# <br />Bus. Phone <br /> Owner/Qperator ‘Fv ___ <br />VO -p <br />City Lo|J.|>fe>^Zip CK'SV <br />Check all appropriate services provided: <br />O 3-compartment sink Electrical hook-ups <br /> Food preparation Toilet and handwashing <br />□ Store refrigerated food . JZ^otable water <br />Overnight parking gs Vehicle wash <br />, 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 ownec^hall notify-the EHD immediately./ <br />Signature Date 7/<7/zc <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />11 ■ To be completed by APPLICANT <br />Business Name "El <br />Owner/Qperator Name <br />Business Mailing Address Ct- <br />City StateCft Zip^5350 Bus. Phfe\0)b001533 Alt. Ph. <br />I. ^CV' ■ 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. <br />Signature____________"________________________________________Date_ I r Uoau