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SAN J O A Q U I N Environmental Health Department <br />-- O L, 1"i TY - <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and 2_ If your commissary is located outside of Sar, Joaquin County also complete section 3. <br />. To be completed by APPLICANT <br />Business Name j)4f'VN0 . j �/x, Lic. Plate # Of 7 �C�� � <br />Owner/Operator Name <br />Business Mailing Address liz,21 _1006111, C_. <br />City -� �/� StaterX Zip 1'-5;24r1 Bus. Ph. <br />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 (END) requirements. If the use of the <br />commissary is discontinued, the permit h eer must notify the EHD. Failure to notify this office may result in permit <br />revocation and penal 'e <br />Signature Date �-� 7— // <br />12. To be completed byCOMMISSARY OWNER/OPERATOR <br />Commissary Name L� ��� �% i ejN fe 'ZD � <br />Address VS- ( fbIr n I MS Bus. Phone 4-A 4 <br />City TZip qSW Owner/Operator2)4,\ J <br />Check all appropriate services provided:-' <br />13"/Vyaste\vater disposal R -3 -compartment sink Electrical hook-ups <br />�Xsolid waste disposal C! Food preparation filet and handwashing <br />Vt & Cold water for cleaning Store refrigerated food l��otable water <br />re dry f d/suppli Overnight parking �G4/t/ehicle wash <br />I, I., hereby state that the information I have provided is current, true and <br />111. <br />correct to the bes of my kn6YvljcF6e7, nd 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 />commissar, ner hall noti the E immediate) <br />Signature ` Date P <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 />Date <br />I"G3- E. HaZe_1iCi� f-,.,eitl'.e i Stocr'A,_•n. Gall ornla 95,205 1 T i102 +.- "1 20 F 209-164-0 13 .'r ,.sjgL .crg-ehd <br />