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Environmental Health Departmei <br />Date V <br />Date 7 <br />DateREHS Signature. <br />Wastewater disposal <br />Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />1868 E Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehc <br />3. To b^completedBy^thf <br />SANJOAOUIN <br />COUNTY - <br />• :< : qr.?vvs here. <br />00^7^^3 <br />___ _ 2-- __________________________________Zip 3 ^'SOOwner/Qperator <br />Check all appropriate services provided: , z <br /> 3-compartment sink Ci Electrical hook-ups <br />□ Food preparation Sl^Toilet and handwashing <br /> Store refrigerated food Potable water <br />fflf^Overnight parking □''Vehicle wash <br />, hereby state that the information I have provided is current, true anc <br />The commissary is located in County. The above food facility meets thi <br />commissary requirements in California Health & Safety Code. The above checked services are available at th. <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />_____Lie. Plate # <br />correct to the best of my knowledgefend meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, th< <br />commissary ownertShall notifyttie EHD immediately. / X / <br />Signature ------------------------ -------------- Date ---------------------- <br />1. <br />Business Name R~ /F <br />Owner/Operator Name j <br />Business Mailing Address_ 1^-0 4" City State^U^Zip ^JT ^-Z/^Bus. Ph. 4 25'- ^2^1 Ph. <br />I C)aCMPZ^ *. 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. i i n r <br />Signature ~:Date-------------- <br />2. ; <br />Commissary Name. L FA# <br />Address.. J Q? 2 Cd N-Si- Bus. Phone_ 77 <br />CityUfU-hriop_____?