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Environmental 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 />Owner/Operator <br /> Vehicle wash <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 />O' Electrical hook-ups <br />0” Toilet and handwashing <br /> Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />— <br />_____________FA# <br />Bus. Phonfe^^-^HSI <br />Qtorux? <br />Alt. pH. ^ ) . < <br />SANJOAOUIN <br />------COUNTY------- <br />Greatness grows here. <br />Date; <br />I 1. To be completed by APPLICANT <br />Business Name,Tgnuwti Sdnckly____ <br />Owner/Operator Name_ <br />Business Mailing Address 1 LO v V. >C i (1 <br />CitY<5H:Cl^Hj,H State CA Zip Bus. Ph <br />i. AnchcVy , 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 hojdermust notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. C ( <br />Signature UIC 0 I \ k <br />2. To be completed by COMMISSARY OWNER/OAERATOR <br />Commissary Name r 1CCZ) <br />Address ‘S ■ UiO LC&U-; <br />City Zip <br />Check all appropriate services provided: <br />0 3-compartment sink <br />□f Food preparation <br />O' Store refrigerated food <br />0 Overnight parking <br />-a, hereby state that the information I have provided is current, true and <br />id meets the California Health & Safety Code requirements. If the food facility <br />ntigns_Qt this agreement, or if this agreement is modified or cancelled, the <br />^immediately. « <br />Date \ ( <br /> Wastewater disposal <br /> Solid waste disposal <br />0 Hot & Cold water for cleaning <br />0 Store dry food/supplies x- <br />i, UiCtYUUu itw <br />correct to the best of my knoi/vledg^ <br />operator fails to comply with the cor <br />commissary owner shall notify the Ek <br />Signature_ <br />3. To be completed by^he-E^V44EALTH jurisdiction outside of San Joaquin Co.