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SAN J O A Q U I N Environmental Health Department <br /> _C0. ; INI , <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 /> 1. To be completed by APPLICANT <br /> Business Name L Lic. Plate# 0 12 S <br /> Owner/Operator Name `4 A.IJ C2V ROW]' Z <br /> Business Mai/l' g Address . W S <br /> City Statef�_Zip SED Bus. Ph2�� "l�q q3 Alt. 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 holder must notify the EHD. Failure to notify this office ma result in permit <br /> revocation and penalties. 1 <br /> Signature SA furl Do A_e7 N1 i2 Z_ . Date <br /> 2 0�" b completed by CQM1ISSARY'tttNERfCPEfATOR' <br /> Commissary Name N�X &1:6m, <br /> Address S ' Y n.t cA Bus. Phone <br /> City G zip Owner/Operator e(1 ISS <br /> Check all appropriate services provided: <br /> Nastewater disposal 0/3-compartment sink 13-"Electrical hook-ups <br /> lid waste disposal ,�od preparation ,�—o'let and handwashing <br /> �t Cold water for cleaning CYStc r refrigerated food [2 Pc ble water <br /> tore dry food/supplies Overnight parking Vehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails t comply with the conditions A this agreement, or if this agreement is modifi d or cancelled, the <br /> commissary m er shall notify the EHD im d ately. <br /> Signature ll\ Date <br /> z <br /> 3. TQ be,completed by tie EN1l HEALTH jurisd'€coon outside;of.San Joaquin Go <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 Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />