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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 />I-2^-2^Date <br />' - Date <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 />Bus. Phone <br />Owner/Operator G > R ‘ <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ❖ Caterer <br />SAN JOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />(^Vehicle wash <br />LQ <br />---- <br />3. 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. <br />FA# <br />ucq- ^-70 <br />H 1I* I <br />■ 'U.pop’ <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name i-Q Co m c r C { Cx <br />Address <br />City CWCWn Zip <br />Check all appropriate services provided: <br />2d Wastewater disposal <br />Solid waste disposal <br />"O. Hot & Cold water for cleaning <br />O Store dry food/supplies <br />I. <br />j 1j. To be completed by APPLICANT____________ ________________________ <br />Business Name_____For 4- *' 11 rx r i C L 6K ' rryp A Lie- Plate # IO 9 C/ <br />Owner/OperatorName iCarCH H ptU ____________ <br />Business Mailing Address 3~? I pjOpMp Cj y" <br />City Stated Zip 95211- Bus. Ph.Alt. Ph. <br />I, fC/nurx.iu tCETfrereby 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_ <br />ClJ 3-compartment sink <br />O Food preparation <br />O Store refrigerated food <br />pLOvernight parking <br />_______________hereby state that the information I have provided is current, true and <br />correct to the best of my 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 cancelled, the <br />commissan^wnet} shall notif^the^EHD immediate^ <br />Signature