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` <br /> Environmental Health <br /> SAN ° "°,"Q~°""" Department <br /> - -C»[a�LN�TY—i-- <br /> COM� <br /> MmSSmRm AGREEMENT <br /> ' <br /> ` <br /> Mobile Food Facility �> caterer <br /> Complete sections 1and 2' /fyour commissary/slocated outside mf San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name <br /> Owner/Operator Name C(?P1611,C14; ef P,-2, <br /> Business Mailing Address ,�_(,;�11�1 <br /> i� <br /> [)i ` tati ^N u8. Ph |t' Ph. /7{/ <br /> |. <br /> hereby state that the above information iauunant,'nueand coneo to <br /> the best cKmyknowledge and agree to utilize my approved commissary in accordance with Co|ihzrnia Health & <br /> Safety Code. and San Joaquin County Environmental Health Department (EHD) requirements. If the use ofthe <br /> commissary is discontinued,the t <br /> revocation qni"erial <br /> Date <br /> Signature <br /> F2-. To be completed by COMMISSARY OWNER/OPERATOR/ <br /> Commissary Nam <br /> 7 <br /> Check all appropriate services pn3v|UgU: <br /> ^� <br /> �/xvvx <br /> � <br /> �� aa�� otardiapoaa| —M�3-compartmenta|nk �� hhook-ups .' <br /> V,"�o|id waste disposal Food preparation 17 dvvuahing <br /> W� MO1& ��O|dVV8�8rf�[Ci��D}Og �� S n��|g�r�t�dfo�d �� water <br /> E� Store dryfood/aupp|ieo ���{�vernight pmrhing Vehiu|evvoah <br /> hereby state that the information | have provided incurrent, true and <br /> correct tothe benHofmyknowledge,and meets the California Health&Safety Code requirements. |fthe food facility � <br /> operator fails to comply with the conditions of this mgreemant, or if this agreement is modified or oancaUed, he <br /> commissary nershall notify the EHDimmediately. <br /> Signature <br /> F-3. To be completed bythe ENV HEALTH jurisdiction outside of San Joaquin C.O. <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 aro available at the <br /> above commissary. Please notify EHDifthe status uftheir operating permit uhanges. <br /> REH8 Signature a <br /> 18G8E. Hoze|bonAvenue i Stockton, California AS2OS1 7 209A68-3420 / P 209 464-0138 1vmmw.ajguuorg/ehd <br />