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� & W U � & � � � ��n��"ron��entaU ��eaK*hU�e��aot��ent <br /> � ~,, " . .=° ~,, ^ `� ~, . ` . ' <br /> ----{-{}L] NTY�---- <br /> C/e"tness q/ow5 here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facilitv * Caterer <br /> � <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 3 / / , <br /> Business NGDn Lic. Plat8 <br /> [)\mDer/]perodorNa0 <br /> Business Mailing Address 7-0 « <br /> |. <br /> hereby state that the above information iscurrent, true and correct to <br /> the�best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> 3afetyOode' and8onJoaquinCountyEnvironmenta| Heo|thDepartment (EHO) requinements. |ftbeuseofthe <br /> commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature <br /> . <br /> RK 1541,60 <br /> WN 10MA00 <br /> FAk <br /> Check all appropriate services provided: <br /> r�i�����| ��_���[M�@[t[D�DtSiDk ���� c|e�TcGlhVok-Ups <br /> � d" <br /> --^�' |idwaste disposal 3/~ FPPdpreparah ��Pn T0i|egaDdh8ndN/@shing <br /> 1r"Hot& Cold water for cleaning 0'ato[erefrigerated food ET"potableVVater <br /> w6toPe dryfUUd/supplies CI'{}nernightp@[kiDg uYnehic|eVx8sh <br /> |. <br /> hereby state that the information | have provided iscurrent, true and <br /> co / / bmthe~- bestofmyknow|e`~e. andmeatstheCa|ifPmioMeo|th&Safety Code requirements. |fthe food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary shall noti the EHDimmediately. <br /> Signature <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 EHDifthe status nftheir operating permit chanQes. <br /> Signature Date <br /> 1DG8E. Hazelton Avenue | Stockton, California S52U5 | T 209460'34201 p 209 46e-)138 | vvvvvv.sjguv.org/ehd <br />