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Environmental Health Department <br />.grow <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date Signature, <br />Vehicle wash <br />Date <br />3. <br />DateREHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />R? coos j <br /> Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />3-compartment sink C <br />^Food preparation <br />O Store refrigerated food M <br />O Overnight parking <br />____, hereby state that the information I have provided is current, true and <br />and meets the California Health & Safety Code requirements. If the food facility <br />•^/conditions of this agreement, or if this agreement is modified or cancelled, the <br />m EHD immediately. . a a <br /> <br />^/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 />1. To be completed by APPLICANT______________________________________ <br />Business Name_ SOUTH F/V.ST STREETGigilj.fae# f, <br />Owner/Operator Name <br />Business Mailing Address IW w lo^ ,ST <br /> <br />City XTZlCKfON/state CAzip^IS7i9l|Bus. 32 Iffi. Ph. <br />I, i V (, |2. ifl A VuNe&by 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 JoaquirpCounty Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued/fWp^ffnit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation andj2££ialties/ _ Xy' h <br />i|| | TO} 5L <br />2. To be completed by COMMISSARY OWNER/OPERATOR________________ <br />Commissary Name\)NW N CMTP-lN^ CENUT <br />Address HU S WiOlV ST Bus. Phone 54IU <br />City cSTj Zip if? Owner/Operator R-0S1 <br />Check all appropriate services provided: <br />Wastewater disposal <br />SftSolid waste disposal <br />X Hot & Cold water for cleaning <br /> Store dry food/suppliesi y esik- A aka <br />correct to the best oHrlXnowlei <br />operator fails to com^ <br />commissary r»*rte^hal <br />Signature <br />h SAN JOAQUIN <br />-----COUNTY- <br />Greotness grows here.