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Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />H Tu 3Lie. Plate # <br />£ <br />Date <br />€ <br />-^Wastewater disposal <br />-f^LSolid waste disposal <br />cgUHot & Cold water for cleaning <br /> Store dry food/supplies <br />commissary owner shall notify the EHD immediately <br />Signature ' -—-C-------------------------- - <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />SAN JOAQUIN <br />COUNTV <br />Commissary Name <br />Ad d r e s s <br />City Zip <br />Check all appropriate services provided: <br /><^?S-3-compartment sink <br />U Food preparation <br /> Store refrigerated food <br />^"Overnight parking <br />REHS Signature ----------------------------------------------------- ---------- <br />1868 E. Hazelton Avenue [ Stockton. California 95205 I I 209 468-3420 I F 209 464-0-38 > ww^gov.oro end <br />Electrical hook-ups <br />■^^Toilet and handwashing <br />*<Lpotable water <br />cx^Vehicle wash <br />I AsfVk., hereby state that the information I have provided is current, true and <br />correct to thebest ofmy knowledge, and meets the California Health & Safety Code requirements. If the foodfacility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />____ _________________nate _ <br /> <br /> 3, To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. J <br />. . . , . County. The above food facility meets the <br />" <br />above eommlssaiy Please notify EHD II lbs status of their obereong permit sheagss <br />Date__________— <br />1. To be completed by APPLICANT <br />Business Name £ | A ______________ <br />Owner/OperatorNam e i yt p Cyaf-Qi Ca <br />Business Mailing Address l/t A U Fp |AU <br />City ‘ofodAorx State Ch Zip Bus. Ph.Alt. Ph. 7 TS'OS <br />I, 'V&yn irxgG , 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 /> Signature ^^5/77 ------------------------ - ----------Date---------—------——---------- <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />■o, Co Viner Ct g j (2,o<P^rcc^crvn FA# <br />v Bus. Phone ^.0.------ <br />Zip Owner/Ooerator u