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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 />Business Name <br />V-yg1- - 2-6Date <br />Date <br />Date REHS Signature <br />COMMISSARY AGREEMENT <br />Mobile Food Facility <> Caterer <br />SANJOAOUIN <br />COUNTY <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />"C&- 3-compartment sink <br /> Food preparation <br />O Store refrigerated food <br />Overnight parking <br />1. To be completed by APPLICANT______________________ <br />ftP / Lie. Plate # <br />Owner/OperatorNam e <br />Business Mailing Address 5T/’f > <br />City Stat^f Zip Bus. Ph.Alt. Ph. <br />I, , hereby state that the above information is current, true and correct to <br />the best of my knowledge ^nd 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 />Signatu <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />_, hereby state that the information I have provided is current, true and <br />sets the California Health & Safety Code requirements. If the food facility <br />s of this agreement, or if this agreement is modified or cancelled, the <br />^immediately. <br />y-jQ" 2^ <br />2. To be completed by COMMISSARY OWNER/ORERATQR <br />Commissary Name ^FA# <br />Address Bus. Phone <br />City j (P\ Zip ^^"5* Owne r/O p e rato r z 0P/Up> <br />Check all appropriate services provided: <br />Wastewater disposal <br />'0 Solid waste disposal <br />BL Hot & Cold water for cleaning <br /> ^t^e dry foocLsupplies <br />I.C^/VV// <br />correct to theT>est of my knowledge, and <br />operator Ws to comply with the condi^ <br />commissary owne/shall notify the <br />S i g n a tu rk__ <br />~y To be completed 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.