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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 />I^To be completed by APPLICANT <br />Business Name Lie. Plate# <br />Alt. Ph. <br />o I — 2-^ 'Date <br />Owner/Operator <br /> Vehicle wash <br />Date <br />Date REHS Signature <br />(/) <br />-H o <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAOUIN <br />COUNTY <br />Creotness grows here. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <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 />Q Wastewater disposal <br />Solid waste disposal <br />■^LHot & Cold water for cleaning <br /> Store dry food/supplies <br />I, wa *3 i zi i_____________ <br />"O <br />'^Electrical hook-ups <br />TS^Toiletand handwashingO ro <br /> Potable water -4 • Q 02° <br />go <br />O <br />a. s <br />\ VEZ\l , ICE CREAk/\ <br />Owner/Operator Name_ ZAH^ P-E(^\/A7 <br />Business Mailing Address rrd. t3c?X A 9 30 ST- <br /> City, P^P^State^Lzip9^J0. Bus. Ph. <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 andj^enalfi^s. <br />Signature > <br />_____________FA#_________________ <br />Bus. Phone 9 H -1 <br />S- <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name_ v) Co <br />Ad d ress 9? HA <br />C i ty Z i p H c-,'T <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />■^Overnight parking <br />, hereby state that the information I have provided is current, true <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food faci <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, ' <br />commissary ownerjshall notify the EHD immediately. <br />S ig n atu re