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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 />Date <br />Owner/Operator <br />Date <br />Date REHS Signature <br /> 3-compartment sink <br /> Food preparation <br /> Sto^e'refrigerated food <br />(Z^Ovemight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ❖ Caterer <br />FA# <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 | www.sjgov.org/ehd <br />przscosh <br />SAN JOAQUIN <br />—COUNTY------ <br />Lie. Plate# <br /> Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />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 notifyJj£J--P^^ . <br />S i g n atu re __________Pate — <br />3. To be completeTby 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 />1. To be completed by APPLICANT___ <br />Business Name la <br />Owner/Operator Name CfisifAn <br />Business Mailing Address 3 ^-{2, ?oQo\C) C'C <br />City SWAlan StateFA Bus. 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 discontinued, H^eyjppjrjiit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address l/W Mt Bus. Phone <br />City zip <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, <br />correct to the best of my knowledge, antr me