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Environmentai Health Department <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 />Date <br />REHS Signature. <br />j <br />^T^-compartment sink <br />I j Food preparation <br />! J Store refrigerated food <br />^Overnight parking <br />Electrical hook-ups <br />^^Toilet and handwashing <br />•<<Potable water <br />(^Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ■ Caterer <br />SAN JOAQUIN <br />C O U N T V <br />209 46^-0'38 1 www.sjgov.org ehd <br />U ru 3 mlo <br />Commissary Name_ <br />Address 0-^0 0 <br />City <br />1. To be completed by APPLICANT <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />County. The above food facility meets the lomZaTZire-nT in above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br /> Date <br />1868 E. Hazelton Avenue | Stockton. California 95205 I T 209 468-3420 1 F <br />Business Name £ I <br />Owner/Operator Name Lb&v~n i O <-4 <br />Business Mailing Address I ~1 2- A u> Fq iA <br />City ‘gWAorx State Ch Zip Bus. Ph.Alt. Ph. 7 5/- 75~0S <br />p CterntrxAG (qgrCtA , 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 ^Sj^/77'-------------------------------------Date------ --------- <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Lca. Co Cka*-.—_-FA# <br />Bus. Phone 1 <br />Zip Owner/Operator <br />Check all appropriate services provided: <br />-gF Wastewater disposal <br />-f?USolid waste disposal <br />iid-lot & Cold water for cleaning <br /> Store dry food/supplies <br />FWVi TMLcCs hereby state that the information I have provided is current, true and <br />correct to thetest oHmy 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 cancelied, the <br />commissary owner shall notify the EHD immediately. <br />r. -----y —------- Date I ------------- <br />Signature---------- --------------------------------