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Environmental Health Department <br />^^00^2. <br />1. To beg <br />Date <br />I 2. To JM <br />Date <br />Date REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 lwww.sjgov.org/ehd <br /> 3-compartment sink <br /> Food preparation <br />EK>tore refrigerated food <br />HJOvernight parking <br />SAN JOAQUIN <br />------COUNTY------ <br />G< eotncss <br />_FA#_ <br />c-t z- Of ZQ <br />1 w 2 —< £ o o fi * <br />O K> <br />5 3E O <br />-Z26 <br /> <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 />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 /> <br />Business Mnme. FoAtA^Xa--------------Lie. Plate - <br />Owner/Operator Name Vo\?TX\Q-\Ck—---------------------------------—-------- <br />Business Mailing Address Ahciat \v^------------------------------------------------ <br /> City 5 \oeV\oX\ Statffil. Zip^T^^*^ Bus- Ph^r ? T 0 ^A^23^lt- Fh.r_------------------- <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. <br />Signature <br />□PFlectrical hook-ups <br />EKfoilet and handwashing <br /> Potable water <br />ivernight parking □ Vehicle wash > 5 ™ <br />I . hereby state that the information I have provided is current, true antfP > <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility m m <br />of this agreement, or if this agreement is modified or cancelled, th^jJ • <br />Commissary Name I C I'S A/ 0------- ---------------------------------- <br />Address, 3H J a PrVtS_____________Bus- phone- <br />City ZiP Owner/Operator. <br />Check all appropriate services provided: <br /> Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, 1 <br />correct to the best of my knowle <br />operator fails to comply with the conditions of this agreement, <br />commissary owner shall notify the EHD immediately. <br />Signature.. <r^ —