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Date <br />Date REHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 | www.sjgov.org/ehd <br />5 <br />IB <br />operator fails to comply with the conditions <br />commissary owner^ralTnbtify the'EHD imme'diatelk <br />Signature ( <br />Environmental Health Department <br />922-SOOOH2. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />If your commissary is located outside of San Joaquin County also complete section 3. <br />(“ £1 SANJOAQUIN <br />COUNTY------ <br />Creotness grows here. <br />13. To be completed by the ENV HEALTH jurisdiction outside of SarTjoaqiiin 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 />2t <br />Commissary Name <br />Address <br />City Zip <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br />S Store refrigerated food <br />B Overnight parking <br />hereby state that the information I have provided is current, true and <br />^Q^A/astewater disposal <br />^G^Solid waste disposal <br />^S^Hot & Cold water for cleaning <br />O Stpre^dry food/supplies <br />tI 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 />operator fails to comply_with the conditions agreement, or if this agreement is modified or cancelled, the <br />) (^1 <br />Complete sections 1 and 2. <br />^JoJEgornphte^ ~~ <br />Business Name 9^0 A, ~^'TAC|Aa/O 0 Plate# 5QC3 1^-3 <br />Owner/OperatorName Au.Srr MaAP CxyT C)____________________ <br />Business Mailing Address (Aj- (s A v-C Z. Z- <br />City,^ ^6 c/ StateM Zip ff^dTUBus. Ph.^ZS-ST? • 11 5t) Alt. Ph. <br />l.-2jbS< 1A orb . 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 pafialtiefe. <br />Signature / Date \ 2- I 0 I 2^ S <br />—- - <br />2. To be completed by COMMISSARY OWNER/OPERATOR 2ZZ Z <br />________fa#______________< > <br />1Zx ___________Bus- Phone q <br />Zip Owner/Operator <br />Cf Electrical hook-ups /Acxf <br /> Toilet and handwashing <br /> Potable water <br /> Vehicle wash