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Complete sections 1 and 2. <br />Lie. Plate# <br />Date <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 /> Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ❖ Caterer <br />SANJOAQUIN <br />------COUNTY------ <br />Greatness grows here. <br />aC.v - <br />T v <br />> I <br />14^-153 <br />Hot & Cold water for cleaning <br /> Store dry food/supplies f” <br />i YCTfcA .TOTA <br />t »r i ti" • <br />operator fails to comply Vitin <br />commissary owner stpHTfioU! <br />Signature <br />If youi commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPUCANT\ <br />Business Name fP <br />Owner/Operator Name CoCQ Q ( H <br />Business Mailing Address X0/ <br /> <br />State Zip^2//2 Bus. Ph Alt. Ph. <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 discontinuedthe. permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation araT?Y’ena|ties- [ / I / <br />Signature Date T> -2^ <br />2. To be completed by COMMISSARY OWNER/OPERATOR ”” <br />Commissary NameJNlON CPTE^INfei TK-UCK <br />Address I~1 I<5^ U /\/1/) /V Bus. Phone\]P\ 5f _____ <br />C'N Zip Owner/Operato r f^QS/~T1 <br />Check all appropriate services provided: <br />Wastewater disposal 3-compartment sink <br />Solid waste disposal Food preparation <br />K Store refrigerated food <br />O 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 />conditions of this agreement, or if this agreement is modified or cancelled, the <br />/EHD immediately. <br />____________________________Date M/H f207S <br />3. To befe6mpleted by 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.