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Q <br />Environmental Health Department <br />Lie. Plate # Hyj U fc ^-8 <br />z-5-zGDate <br />REHS Signature.Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Electrical hook-ups <br />EEl’oilet and handwashing <br />CKPotable water <br />B^Vehicle wash <br />SAN JOAQUIN <br />------COUNTY------ <br />Greatness arows <br />, - -- <br />FA# <br />(20^334-25'^3 <br />■■ <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EFJD immediately. <br />Signature <br />3. To be completed by th^NV HEALTH jurisdiction butside 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 />Commissary Name___' <br />Address bJ. CxAVA <br />city loA\_____zip gcz-M 0 <br />Check all appropriate services provided: <br />Wastewater disposal <br />□''Solid waste disposal <br />B^Hot & Cold water for cleaning <br /> Store dry food/supplies <br />_________ <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Comp/ete seef/ons f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />ri.Tbbe^dmpl^edbyAPPLItWJT <br />Business Name VckCo\ <br />Owner/Operator Name ^(esseA<Ci VAC-vr-1 <br />Business Mailing Address ~yAv-AeY\c\ <br />City^C^^ Statec^ Zip Bus. Ph. l^Kpg^-MUPAit. Ph. j L <br />I XeSJen\Q 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 <br />Hr 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />□^Overnight 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 />* - <br />Date ' <br />2 To be completed by COMMISSARY OWNER/OPERATOR <br />CaUo <br />Bus. Phone <br />Owner/Operator