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Environmental Health Department <br />Date <br />Bus. Phone <br />Date <br />REHS Signature Date <br /> Electrical hook-ups <br /> Toilet and handwashing <br />Potable water <br />M Vehicle wash <br />Wastewater disposal <br />p Solid waste disposal <br />p/Hot & Cold water for cleaning <br />Store dry food/supplies <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 |-www.sjgov.org/ehd <br />FA# PC \ Q <br />tpO0' " b ki. - k'? <br />Cl I <br />3. To be 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 />Owner/Operator <br />SAN JOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary ownepshall notifv the EHD immediately. <br />Signatu re <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 section 3. <br /> <br />| 1- To be completed by APPLICANT <br />Business Name^Lie. Plate # <br />Own er/Operator N a me <br />Business Mailing Address Vgk.cwsceyj.\ <br />City\^vM-er>^StateCA-Zip CyCY^Bus. Ph.Alt. Ph. ^04-06^ <br />I/->, 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 penalties. <br />Signature Date <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Poi S <br />Address ' <br />City Zip <br />Check all appropriate services provided <br />3-compartment sink <br />0 Food preparation <br />Store refrigerated food <br />_Z 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