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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 />Lie. Plate# <br />Date <br />] <br />® Vehicle wash <br />Date <br />completed by the ENV HEALTH jurisdiction outside of San Joaquin Co.3. To <br />Date REHS 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 />KI 3-compartment sink <br />S Food preparation <br />IS Store refrigerated food <br />QI Overnight parking <br />® Electrical hook-ups <br />El Toilet and handwashing <br />Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 [www.sjgov.org/ehd <br />Commissary Name U KJ H aj <br />Address ) ] f] 3 <br />City 5?4 J <br />and penalties. i <br />Date \ I ) (/ 0 ^--5 <br /> <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Cc\Tr.€/^Cq ______________ <br />(J AJ jy /Bus. Phone 20 j' 2.^ <br />Zip Owner/Operator £6 77 <br />Check all appropriate services provided: <br />Q Wastewater disposal <br />D Solid waste disposal <br />X Hot & Cold water for cleaning <br />H Store dry food/supplies <br />i. \JeSlLA- 7yQ2)4 , hereby state that the information I have provided is current, true and <br />correct/o the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply wiftUhe^opdjtons of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shaljZotifyj^^^mipmediately. y y <br />Signature Date / / I O' IA <br />SANJOAQUIN <br />------COUNTY------ <br />Greotness grows here. <br />1. To be completed by APPLICANT_______ ______ <br />Business Name_ ~T M'-U A (-? i f MA 15 _____ <br />Owner/Operator Name I U jjl O <br />Business Mailing Address ZA- A I M ^7 <br />City VlUCl^t G State fA Zip c\ S/C A Bus. Ph. Alt. Ph. <br />I, , hereby state that the above information is current, true and correct to <br />the be£/ 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 penaltie: <br />Signature