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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 />Vehicle wash <br />JDate <br />REHS Signature.Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <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 />□T Electrical hook-ups <br />EK^Toiletand handwashing <br />Q/Rcstable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br /> /13 / <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />2. To be completed by COMMISSARY OWNER/QPERATOR <br />p j\— <br />.A '\< &CiF F j _____ <br /> Owner/Operator <br />SAN JOAQUIN <br />------COUNTY------ <br />CreCit grows here. <br />1. To be completed by APPLICANT <br />Business Name \ Q > <br />Owner/Operator Name P.-nsVtcxM <br />Business Mailing Address ^7/^. <br />CitySkxXlnA State Cd Zip^ZZ?- Bus. Ph. ^f/Xj'Alt. Ph. <br />I,, 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 discontinuedjii^^-mit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties.* <br />Signature <br />iff Wastewater disposal <br />EH Solid waste disposal <br />-U Hot & Cold water for cleaning <br />□^tore dry food/supplies <br />I, j <j <br />Bus. Phone ^"6>/ <br />Commissary Name / / F-O r fl i «•> <br />Add ress 2 V /c> Q. A < ^>CjF F <br />City Zip O 6 <br />Check all appropriate services provided: <br />□^compartment sink <br />Ef/pood preparation <br />□/store refrigerated food <br />f Overnight parking <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 owner shall notify ^he-EHDjmmediately. <br />Signature <br />I