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Environmental Health Department <br />G <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate # rfj 2^ <br />/ -Date <br />Date REHS Signature. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />—FA#_________________ <br />2,5 5V <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Rwi-mo <br />SAN JOAQUIN <br />-COUNTY- <br />OLElectrical hook-ups <br />EKoilet and handwashing <br />^Potable water <br />(^Vehicle wash <br />(22^/^ • <br />________Bus. Phone <br />S ? Owner/Operator <br />3. To be completed by the ENV HEALTH jurisdiction outside of SanJoaquin 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 />a iv <br />Date 2-^/' <br />1. To be completed by APPLICANT <br />A <br />BusinessName igcQS I CKq(gLv <br />Owner/Operator Name mlcCo tv O (vyc J LtCvA- <br />Business Mailing Address ^i\ i T1 Leks fl tA <br /> City / Statef^ ZioQS^O Bus. Ph. 7?^7 Alt. Ph. <br />i. ___, hereby state that the above information is current, true and correct to <br />the best oTmy knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, ano 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^vA z? <br />Signature_____[ J )JOf / <br />13^3-compartment sink <br />EPFood preparation <br />Q>8tore refrigerated food <br />vernight 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 of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />S i g n a tu re__________ <br />2. To be completed by COMMISSARY OWNER/OPERATQR <br />Commissary Name <br />Address 6'Z-4> S <br />City Zip <br />Check all appropriate services provided: <br />□pWastewater disposal <br />EP^olid waste disposal <br />[JpFlot & Cold water for cleaning <br />/Qyfetore dry food/supplies <br />I.____/\ Z _______