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4 -_. O. SAN JOAQU l N Environmental Health Department <br /> —COUNTY— <br /> Greatness <br /> COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility♦ Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County a�so complete section 3. <br /> 1 . To be completed by APPLICANT <br /> Business Name Lic. Plate# �a0 <br /> Owner/Operator Name Aa4t <br /> Business Maing Address �� <br /> City Stat Zip . 446 Bus. Ph Alt. Ph. <br /> 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 vvith 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 /> Signatu' Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> G <br /> Commissary NameY16, -FA# <br /> Address l/ Bus. Phone <br /> Cit Zip t� Owner/Operator <br /> Y <br /> Check all appropriate services provided: <br /> 11 Wastewater disposal JE 3-compartment sink RA Electrical hook-ups <br /> ® Solid waste disposal O Food preparation d Toilet and handwashing <br /> ® Hot& Cold water for cleaning O Store refrigerated food 13 Potable water <br /> 13 S e"odes Vern ight parking Veh cle wash <br /> , hereby state that the information I have pr vided is current,true and <br /> correct to the best of my knowledg ,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 p r shall notify the HD immediately <br /> Signature ` titG�iL� 2 Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. The abo e food facility meets the <br /> commissary requirem9pts in California Health & Safety Code. The above checked se ices are available at the <br /> above commissary. ease notify EHD if the status of their operating permit changes. <br /> REHS Signature/ 51 1 <br /> z- U Date <br /> 1868 E. Hazelton Avenue I Stockton; California 952051 T 209 468-3420 1 F 209 464- 138 1 www.sjgov.org/ehd <br />