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`�— ' ,� � 8 � �� 8 ��� <br /> ���0wJ� A��|Q� �g Environmental Health Department <br /> ---[{}UNTY-- ' <br /> G,00mau �rsw� 6r�� <br /> COMMISSARY AGREEMENT <br /> Mobile Food F@Cilif» + caterer � <br /> Complete sections Iand 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> � <br /> Business Name � <br /> Owner/Operator Name_ S I V1 <br /> 1, 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) requirem.ents. 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 /> Signatu _Ca <br /> Add 7r�ss Bus. Phone c:>C:5; <br /> itV <br /> City <br /> Check all appropriate services provided: <br /> M-W | g3-3-oornpartnnentainkhook-ups <br /> �o||� vvaote disposal d prepanation ;&-�-T�6�ile' d h dvvamh|ng <br /> j�&~�ot & Coldvvoterfor cleaning �@ ��ra reoning � efrigerated food �' <br /> Xjte dry food/suppl'e <br /> ehicle wash <br /> | VC <br /> hereby state that the information | have provided iacurrent, true and <br /> correct tothe best cfmyknowledge, and meets the California Health&Safety Code requirements. |fthe food facility <br /> operator fails | ih the conditionse <br /> commissary <br /> Signatu Dat <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked aen/icao are available at the <br /> above commissary. Please notify EHDifthe status oftheir operating permit changes. <br /> REHS Signature Dat <br /> 1868E. Hazelton AvenueI Stockton, California 962O5 ! T 209 468-3420 F 209 464-0138 � ew� �govorg/ehd <br />