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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 /> Date <br />Date REHS Signature. <br />Electrical hook-ups <br />Toilet and handwashing <br />Q> Potable water <br />EJ/Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />COUNTY <br />3. TX&exompleted 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 />______Lie. Plate# <br />Or- <br />S^stc <br />correc <br />operator fails to ccfrr <br />commissary oy/ner s <br />Signature <br />3-compartment sink <br />Food preparation <br />'Q; Store refrigerated food <br />Overnight parking <br />____, hereby state that the information I have provided is current, true and <br />myYnswIedge, and meets the California Health & Safety Code requirements. If the food facility <br />iply with yie conditions of this agreement, or if this agreement is modified or cancelled, the <br />latLnofj^jthe EHD immediately. > <br />T-U- <br />1. To be completed by APPLICANT_________ <br />Business Name. Uflhon Gib ' <br />Owner/Operator Name ■ <br />Business Mailing Address \^. "] i <br />City LCa /K State C /Q-Zip Bus. Ph.^U6F6/6/C>' ^/ZZAIt. Ph.9jj^S^2Zp3'T <br />i, ferilp 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 permipaolder must notify the EHD. Failure to notify this office may result in permit <br />revpca'fion-and pe/aTties. <br />Signature^lrA^ic^J^______________________Date_ U|5/3S <br />2. To be completed by COMMISSARY OWNER/OPERATOR_______________ <br />Commissary Name. Unitn wrU'ii-ui TnxK fa# <br />Address I ~] j Z) Bus. Phone ^0^" <br />C ity /O Z i p 0 Owne r/O pe r a to r V/ <br />Check all appropriate services provided: <br />'p Wastewater disposal <br />Solid waste disposal <br />Ek Hot & Cold water for cleaning <br />Eh Sttfre dry food/s up plies <br />PbtKA gS&A- <br />to the best of