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Environmental Health Department <br />Date <br />] <br />-7-2/-2/Date <br />Date REHS Signature. <br />PROS 3^? <br />• I ■ 81-' : <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 0 Caterer <br />SANJOAOUIN <br />C O U N I Y <br />Electrical hook-ups <br />ET-Toilet and handwashing <br />^£<£potable water <br />Vehicle wash <br />^<70 <br />'Zi-bp'’ 4rh€/-^- <br />3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />^Rj^Overnight parking <br /> _________, hereby state that the information I have provided is current, true and <br />correct to theTest of my knowiedge, and meets the California Health & Safety Code requirements. If the food facility <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3 <br /> <br />f-l. To' be completed by APPLICANT <br />Business Name Mo, t4! <br />Owner/OperatorName 51 IClry? <br />Business Mailing Address 2- S/., ■ VcA <br />City State Zip 9 Bus. Ph. ^ocl 7- Alt. Ph. <br />I. Gq0fA 7 Cl CC,*>. 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 pej <br />Signature <br />Commissary Name. <br />Address XA 0 0 <br />City <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />^GHot & Cold water for cleaning <br /> Store dry food/supplies <br />I,w (^7(4 <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />Signature ----- ---------------- t^rrlpieted^ the ENV HEALTH jurisdiction outside of San Joaquin Co. j <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. Pleasp'fiotifv EHD if the status of their operating permit changes. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Lie. Plate# 7 7£ J <br />7-24-2^ <br />|..2.To be completed by COMMISSARY QWNER/QPERATOR <br />Covnz.ru at Cu-rp_________fa# <br />£ ■ ci-1 It) Bus. Phone 7-c^ <br />Zip 4 ST-O S> Owner/Operator G- ■ ,z