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Date <br />Date REHS Signature. <br />20 Electrical hook-ups <br />0 Toilet and handwashing <br />Potable water <br />Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility < Caterer <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notifydhp EHDhpmediately. / iSignature f -------- <br />SAN JOAQUIN <br />------COUNTY------ <br />Grrnnr.^ Acre. <br />Lie. Plate # <br /> Zip G Owner/Qperator 52^ <br />Check all appropriate services provided: <br />Cp Wastewater disposal <br />E| Solid waste disposal <br />fir Hot & Cold water for cleaning <br />Store dry food/supplies <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Environmental Health Department <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />S' Overnight parking <br />I, lO > 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 />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />TTdrte completed by ' - <br />Business Nam^2- <br />Owner/Operator Name o —- <br />Business Mailing Address *3^0Pi Y/lp.'Ty <br />City^dCk-VQ’A Stated Zip4^?0fo Bus. PhTOQ-T 15-Alt. Ph.^^-T^rCW, <br />I, fWfc> , 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 />SiqnatureMibffiT) _________________Date*"^ | | .OX.: <br /> <br />fy To be completed by CQ^MiSSARY QWTe1T0PERATOR~~ <br />Commissary Name /r -fer iWv /Ss/ I ny A#--------- <br />Address Bus. Phone <br />City Zip 6 Owner/Qperator 52^ <br /> <br />_____________________________________________________i * j-. j -it-./ v*-. j -- —■—. — - — - -J--------------------------------------1 <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.