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t <br />Environmental Health Department <br />Date <br />Date <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_____‘ <br />Electrical hook-ups <br />Toilet and handwashing <br />OF Potable water <br />[^Vehicle wash <br />SAN JOAQUIN <br />COUNTY <br />Business Name L Lf - <br />Owner/Operator Name ^Y'^Oj^yxa jZfcbN <br />Business Mailing Address /(QPJ (OSpYry <br /> State C/3 Zip Bus. Ph. J 2^0 Alt. Ph. <br />H ■ hereby state that the above information is current, true and correct to <br />thfe 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 Date (0 ? A-? <br /> | 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name FA# <br />Address Bus. Phone 'Zo A / - <br />City-----SJ-or/tcTivd Zip <7 Owner/Operator CtA-Zo <br />Check all appropriate services provided: <br />Wastewater disposal <br />TjQ, Solid waste disposal <br />6P Hot & Cold water for cleaning <br />EjJ^Store dry food/supplies <br />I. 12^/19 <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Comp/ete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLJCANT | <br />________Lie. Plate # Z^t/n^S^TiO <br />______________ <br />fop3-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 />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 EHD immediately. <br /> <br />Stature Date 3/^5//^ <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 />REHS Signature