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"AN <br /> MUM <br /> M Environ mental Health Del: artn'ient <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1, To be completed by APPLICANT <br /> Business NameLic. Plate# �u�p� <br /> Owner/Operator Name ( Bd� <br /> Business Mailing Address i30 QiydQ <br /> City StateMZip Bus. Ph.d,0q-,9lg &1-11J' Alt. <br /> 1,0�g4 Cartrab�s� �kCeo CO#V45 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) requirements. If the use of the <br /> commissary is discontinued, the permit hoOer must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe Iti . <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FAr <br /> Address bus. Phone p 4/—Z/c7Z/_) <br /> City AZip q$o?D S IrOwner/Operator ¢J• � � Uv�y[� <br /> Check all appropriate services provided: <br /> M Wastewater disposal & 3-compartment sink 81 Electrical hook-ups <br /> 14 Solid waste disposal 11 Food preparation e Toilet and handwashing <br /> JW Hot & Cold water for cleaning 0 Store refrigerated food El Potable water <br /> E7 Store dry food/ upplies 6 Overnight parking ('Vehicle wash <br /> I, 't1n0,+1�2 , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, nd meets the California Health&Safety Code requirements. if the food facility <br /> operator fails to comply with the ditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissar, owner shall noti EHD imme tely. <br /> Signature Ai4 a Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> RENS Signature Date <br /> 1863 E:. Ha7eltOn -,,'v�nUF' I Stockton. California 93205 1 T 209 46$-3420 1 F 209 46-4-0-138 1 sig�`;.c'rg'ella <br />