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Environmental Health Department <br />_Lic Plate# <br />Date <br />Date REHS Signature. <br />SAN JOAQUIN <br />COUN T y- <br />/of this agreement, or if this agreement is modified or cancelled, the <br />tJ5 Electrical hook-ups <br />JET Toilet and handwashing <br />^21 Potable water <br /> Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete se <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />hereby state that the information I have provided is current, true and <br />Commissary Name_ <br />Ad d ress W/ <br />1. To be completed by APPLICANT <br />Business Name <br /> Owner/Operator Name MAyAlMi-------------------- <br /> <br />Business Mailing Address ^QC k) Wxv^\—-------- <br /> City _________Stated Zip A Bus Ph--------------------------------A,t- Ph----------------------------- <br />■ ‘KsfiA UaAkxdU . herebystate that the above information ,s current true and c°rre^ the ‘b^CoYmy knowl^ge and agree to utilize my approved commissary acn7rdanC!Xhtf aX'^eof the <br />Safety Code, and San Joaquin County Environmental Health Department |t errnit <br />commissary is d.scontinued, the permit holder must notify the EHD. FaHure to notify this office may result m perm.t <br />revocabon and penaltie^^xS? | /c. ,na.e I 17^________ <br />Signature X --------------------------------------------------------------------------------H h <br />2. To'be completed by COMMISSARY OWNER/OPERATQR <br />/ Str-eeJ- c_ fa# <br /> fj. TuZ/e L- Bus. Phone, ------ <br /> q i ty '-yjgf Zip Owner/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 />! NiLo/aS , ----------------- - • <br />correct to mVbesl of my knowledge, and me^s the California Health & Safety Code requirement^ If the food tac.hty <br />S>r fails to comply with th^conditon/of this agreement, or if this agreement rs modified or cancelled, the <br />commissary owner^sJ>«ft3otiJ/thaEHD immediately //V/2, <^» <br />Signature]------------------------ -Date ' / <br />Pa^fobe'cornpletedbyjthe ENV HEALTH jurisdiction outside ofSan Joaquin Co. <br />IS located in —____________County. The above food facility meets the <br />^mrm^X5requirements 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 permtt changes. <br />1868 E Hazelton Avenue | Stockton. Califorma 95205 | T 209 468-3420) F 209 464-0138 lwwwsjgov.org/ehd <br />