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Environmental Health Department <br />I <br />Lie. Plate # <br />SV <br />Date <br />REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T <br />SB <br />£9 Electrical hook-ups <br />0 Toilet and handwashing <br />0 Potable water <br />£3 Vehicle wash <br />Q 3-compartment sink <br />O Food preparation <br /> Store refrigerated food <br />ElLovernight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 4 Caterer <br />209 468-3420 | F 209 464-0138 | www.sjgov.org, ehd <br />U'G.Vj <br />Owner/Oaerator G , F ■ <br />2.E <br />Al ■!.. <br />are available at the <br />- i r OT? <br /> Date <br /> <br />he ENV HEALTH jurisdiction outside of San Joaqui <br />. . in County. The above food facility meets theThe commissary is located in--------------------------------------------—----~ <br />commissary requirements in California Health & Safety Code. The above checked services <br />above commissary. Please notify EHD if the status of their operating permit changes. <br /> Date <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />It ^e e0mp>eted by APPLICANT <br />Los To <br />2 <br />■ SAN.JOAQUIN <br />r ------COUNTY— <br />Creotness grows het? <br />BusinessName______L-QS to ______________ <br />Owner/Operator Name UCC. •z.csv^ <br />Business Mailing Address 2 3^^2. \ , <br />City 6^0^^ State CP-zip ‘ISZ&S Bus. Ph.Alt. Ph. 2^- 8^- <br />I, vt-S-C-Hr Pr \ "Z-O 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, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. . , > <br />/ / (p n ' /O ? jSignatu re------------------------------ ----------------------------------------Da e--------- <br />^IBBiaWi^frBPPMMISSARY OWNER/OPERATOR <br />CommissaryNam e | c\ 1 c t (\ |F A#------- <br />Address^ '2^60 \ Lv aAu\j Bus. Phone <br />City €'Xe(AiLi \ Zip ri 'S20 S Owner/Operator__(L_jL___'Y'L (LJ----- <br />Check all appropriate services provided: <br />0 Wastewater disposal <br />(3 Solid waste disposal <br />P Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i L .a a _________- heret)ystate that the informatiori 1 have Provided is current-true and <br />correct to the best of my knowledge, and meels 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, th <br />commissary owner shall notify the EHD immediately. on y <Signee L2L-.______________ Date---------[p '