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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 au goo _ _ ic. Plate# <br /> Owner/Operator Name (vELJ _ / <br /> Business Mailing Address po'- ✓1 k r rtev� -4� <br /> City Stat Zip J Bus. Ph. S2,Z0 _Alt. Ph._ ObLfi <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, anian Joaquin County E vironmental Health Department (EHD) requirements. If the use of the <br /> commissary s d c ntinued, thpermit ho der must notify the E Failure to notify this office may result in permit <br /> revocation and ties. <br /> Signature Date 1 <br /> 2. To be com I ed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 1V16 b 0 CIRRI-IRl0f� I Kt1C-K CEI )fCft FA# <br /> Address 1717 S. UAI(94 57': Bus. Phonec2e)q) 2?"r-Jay/L <br /> Citys1-0 ck-ra kl . CA Zip 15-Aa G Owner/Operator 9R7— IV [� <br /> Check all appropriate services provided: <br /> Q,�Nastewater disposal 13/3-compartment sink Ef"'E lectrical hook-ups <br /> al/Solid waste disposal G2rFood preparation Toilet and handwashing <br /> L_9_�Hot & Cold water for cleaning BY Store refrigerated food Potable water <br /> by/Store dry food/su plies (Overnight parking L7 Vehicle wash <br /> /, hereby state that the information I have provided is current,true and <br /> correc to the best of my knowledge, and 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 /> commissary owner II no t EHD im diately. <br /> Signature Date /.Z 3 2- a <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 Ccde. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their -perating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 wwtiv.sjgov.crglehd <br />