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^ Uriv «� � &� ��� � � 00 &� ^ <br /> ��88������0U �N Environmental Health Department <br /> �~ <br /> —COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections Yand 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Owner/Operator Name Z1'>117"f14 <br /> Business Mailing Address- 71, IhI <br /> Ci | Bus. Ph L Ph <br /> enebyobutethcdtheabnveinfonnotinnimcunent.bonondoonectto <br /> the best of my knowledge and ogreofo utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. |fthe use ofthe <br /> commissary indiscontinued, the permit holder must notify the EHO. Failure tnnotify this office may result inpermit <br /> revocation <br /> Signature_ Date—/–2 –J:61 <br /> am <br /> Commissary Name -27L-1-7 <br /> Check all oppropheteaervioes provided: <br /> 13'VVaotavvoterdiopooa| -compartment sink ]e&-t|ecthca| hook-upe <br /> S�~1� E]"Toi|atand handvvoohing <br /> b- d water for cleaning �'�torefrigeratedfood 8[��z <br /> tore dry food/supplies P-lovernight parking P-Vehicle wash <br /> |. hereby state that the information | have provided is current,true and <br /> correct tothe best ofmyknowledge, and meets the California Health&Safety Code requirements. |fthe food facility <br /> operator fails comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary <br /> Signatur Date <br /> The commissary in located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services aro available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Dot <br /> 18S8E. Hazelton Avenue | Stockton, California 0S2O51 T 209468'34201 F 209 464-0138 1vmmw.sjgov.orQ/ohd <br />