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Environmental Health Department <br />1. To be comi <br />Date <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 I F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />------COUNTY------- <br />Greotnw QrOni her. <br />y r <br />Electrical hook-ups <br />Toilet and handwashing <br />Sr Potable water <br />Vehicle wash <br />_FA# <br />7a - T-G/- / <br />S V) (o <br />£g/wastewater disposal <br />Solid waste disposal <br />Gj/Hot & Cold water for cleaning <br />□/store dry food/supplies <br />f-----------------hereby state that the information I have provided is current, true and <br />co^ect 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 FHD-immertiatply. , <br />SignatureO^T^'Date | (? <br /> <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 />REHS Signature <br />Plate # <br />commissary is discontinued <br />revocation and pegattfesT"^ <br />Signature x <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 />leted by APPLICANT <br />Business Name T0^ T/ /) <br />Owner/Operator Name <br />Business Mailing Address PV / <br /> <br />City.5? O State^ip-^g/Bus. Ph.a,,. Ph <br />the hoot Z------TT-------------------------------- hereby sta*e th3* the above information is current true and correct tn <br />SafAK r h y k"°wledge and a9ree to utilize my approved commissary in accordance with California Health & <br />ety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use ofttte <br />irmrt holder must notify the EHD. Failure to notify this office may result in permit <br /> Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR-------------------------1 <br />Commissary Name G | | n I Supply <br />Address 2W 4,'r^ry ____________Bus phone_ <br />City-—SG(XTt?/\______Zip *7 fe Owner/Operator______). <br />Check all appropriate services provided: <br />P3-compartment sink <br />□K Food preparation <br />Store refrigerated food <br />M Overnight parking