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Environmental Health Department <br />G <br />■I <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 />Date <br />■* <br />Date REHS Signature <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 />Cj Electrical hook-ups <br />□^Toilet and handwashing <br />□^Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />COUNTY------- <br />recTTness arows here. <br />Owner/Operator <br />/ 9 ^>6 <br />g 1^\ ca > cm <br />(q CkA_______ <br />XiT_____ <br />Bus. Ph. ^^^/<?Alt. Ph. <br />[ L To be completed by APPUCANT <br />Business Name \Qr \\,£r > <br />Owner/Operator Name P s VICkW <br />Business Mailing Address ^7 /£ <br />City State C/4 Zip 7 Z <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 discontinuedUMrarmit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties..^ T <br />Signature <br />Bus. Phone <br />7. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name / / Qj r p | <br />Address 2 C, <br />C i ty <C~1ruc^V<M Z i p O <br />Check all appropriate services provided: <br />□^Wastewater disposal □/3-compartment sink <br />Er Solid waste disposal Food preparation <br />-C^ Hot & Cold water for cleaning Q^Store refrigerated food <br />□^tore dry food/supplies f Overnight parking <br />I. U, 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 |ha£F[p immediately. , . <br />Signature ~Date I 3 p <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co.