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MAR 0 9 2026 <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />\ 2- I ?>ol 2- rDate <br />Owner/Operator <br />Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />Date REHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <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 />3' Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />Commissary Name <br />Address <br />Environmental Health Department <br />RECEIVED <br />^fjWastewater disposal <br />^Q Solid waste disposal <br />Hot & Cold water for cleaning <br /> Storendry food/supplies <br />I. ^4.6^ <br />SANJOAOUIN <br />------COUNTY------ <br />Greatness grows here. <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />____FA#_______ <br />1 Bus- Phone <br />City y1 Zip Owner/Operator \ C3 , <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br />E3 Store refrigerated food <br />& Overnight parking <br />\ 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 pfTfNs agreement, or if this agreement is modified or cancelled, the <br />commissary owne^shaTnbtify thof EHD immediately. i / - <br />Signature ' " _________Date <br />COMMISSARY AGREEMENT environmental health <br />Mobile Food Facility ♦ Caterer department <br />1. To be completed by APPLICANT 1 <br />Business Name_ IA-C^A/vC* 0 M/WifrLic. Plate # 3 C) L- 3 H C 3 <br />Owner/Operator Name MaAO <br />Business Mailing Address 2-A "S" (A>- CSOXO/A /X Z, 2-________________________ <br />City StateCA Zip Ts'd^Bus. Ph.^ZS-ST7 • II dt> Alt. Ph. <br />I, TjuSC . M tA pTb , 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 pohaltie^ <br />Sig nature ..