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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 />Date <br />modified or cancelled, the <br />Date <br />Date REHS Signature. <br />Electrical hook-ups <br />Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />CD cn <br />2 <br />G <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />SAN JOAQUIN <br />------COUNTY------ <br /> 3-compartment sink <br />O Food preparation <br />Store refrigerated food <br />Ng Overnight parking <br />, hereby state that the information I have provided is current, true and <br />Commissary Name_ <br />Address 24 I /I £ ■ <br />City -ffb C Zip S4 Owfier/Operator <br />Check all appropriate services provided: <br /> Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, <br />operator fails to comply with the conditions of this agreement, or if this agreement is <br />commissary owner shall notify the EHD immediately. <br />Signature -----------------------Date N 6------------------------------ <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 />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />^09311^ <br />z = - <br />p hi ?! <br />c <br />ncorrect to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility M <br />- • • -------------------* modified or cancelled, the <br />1. To be completed by APPLICANT________~ <br />Business Name -S ICt" Lie. Plate# <br />O w ne r/O peratorNam e CJ r¥T f?C hr P- 2 AT K H o __ <br />Business Mailing Address S93o <br />City State Zip ^Bus. Ph. 7^/ SSb^ Alt. Ph., <br />I. 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 />2. To be completed by COMMISSARY QWNER/OPERATQR <br />f / CK GO FA# <br />J fiVA?________Bus. Phone <br />co 3 <br />H C o ± ? <br />0 M <br />> 73 <br />< , Pi <br />3 ■I