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. . <br /> � . <br /> �A� <br /> UNTY-- <br /> ``- <br /> COMMISSARY AGREEMENT <br /> Mobile Food F@ciiHn � caterer ' <br /> Complete sections fand 2. lfyoOrcommissary/slocated outside ofSan Joaquin County also complete section 3. <br /> 1. To be Completed by APPLICANT <br /> Business Name1qV Lic-Plate <br /> Ovvneri'Operator Name <br /> { <br /> hereby stale that the abdveinformation isounent.true and correct to <br /> the beet of my knowledge and agree to oti|ica 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 isdiscontinued,-the permit holder must notfy-the EHD. Failure tonotify-this office may result inpermit <br /> revocation and penalties. <br /> Signature Date <br /> 12. TO be completed by COMMISSARY OWNEPJOPEERATOR - <br /> ._ <br /> Commissary Name <br /> Address CP —Bus. Phone <br /> cOwner/Operator <br /> Check all appropriate services provided: <br /> �� <br /> VV8stevvaterdisposa| �� 3'connpu�n�entsink �w' B�ct�oa( hook-ups <br /> "=~�-Ud *ast�diaposa| �� �oodpnspons�on no~�"i|etandhand�aahing <br /> °-`�ot {LCold water for cleaning Tn"S-�-nsrefhgenatedfood ��P^tab|evvatar <br /> ��� <br /> o� bIOre dryfOod/eupp|ies �&,6ve[OiQht parking 1- Vehicle wash <br /> hereby state that thainforma�on | have provided ioou�en��ueand <br /> corn*nT'tAeuaatof-mynn-mm| dga. and meets the California Health &Safety Code requirements. |fthefood facility <br /> operator fails to comply with the condDionn of this agnaament, or if-this agreement is modified or cancelled., the <br /> commissary owner shall notify the EHOimmediately. <br /> Signature at <br /> 13- 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 /> aboveoommieeory. Please notify EHD |fthestatus nfthairoperatingpermit changes. <br /> — <br /> REHS Signature Date <br /> ��8 E. {�on�v�nus | Stockton. California gE2�5 � T 2O��8D-342O | F 2OQ4G�-Oi3O <br /> 'L868Hoz� | pe/�.��Qovorg/�hd <br />