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correct to the best of my knowledg <br />operator fails to co ydith e <br />commissary own r stall not, <br />Signature <br />SAN JOAQUIN Environmental Health Department <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 />rl. To be completed by APPLICANT <br />Business Name <br />_ Lic Plate <br /> <br />Owner/Operator Name <br />City pr. State-it6c Zie53.-2-0 Bus P[-) .2(}i)Z1 -7(()'"IL9 )(' Alt Ph. 2° -0611 <br />I, I \ACP.O.,116e Oc),Rx(c),__ , hereby state that the above information is current. true and correct to <br />the best 0 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 penajtjes-), <br />Signature <br /> <br />(________,---- ------,-.- <br />_l Date Oi <br />7-'72 <br />Address <br />City IlVt 5T p Owner/Operator <br />Check all appropriate services provided <br />X Wastewater disposal 3-compartment sink <br />y Solid waste disposal K"Food preparation <br />y Hot & Cold water for cleaning 24 Store refrigerated food <br />Overflight parking <br />hereby state that the information I have provided is current, true and <br />, and rnefOs the California Health & Safety Code requirements If the food facility <br />onditicmst this / greement, or if this agreement is modified or cancelled, the <br />or) <br />K) immediately z!-/ V <br /> Date <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 />RENS Signature Date <br />1P,68 E Hazelton Avenue I Stockton California 95205 I T <br />Business Mailing Address <br />2. To be-completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 1\AP\--__X---01-- 0 1, FA# <br />Bus Phone <br />6i< C &I kJ <br />)( Store dry food/supplies <br />OlKifj <br />X Electncal hook-ups <br />,X Toilet and handwashing <br />Potable water <br />)(, Vehicle wash