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Environmental Health Department <br /> ;. <br /> COMMISSARY AGREEMENT <br /> Mobile r=ood Facility 4 Caterer <br /> Complete sections ' and 2. f;your commssari,s iocarec cutsioe of San Joaquin; County also complete section 3. <br /> Business Name rO Lic Plate <br /> Owner/Operator Name Y S �' pe 1 <br /> Busine s Mailing Address N 1 l� (400 SA city StaterA ZipeBus, Phlo "-J�M Z�t�It. Ph. <br /> ,h,areb}' S?atB that the above informaiion is current.true and correct to <br /> the best of my knowledge and agree to utilize me approved commissary in accordance with Calirornia Health & <br /> Safely Code, and San Joaquin County Environmental Heaith Department (EHD) requirements. if the use of the <br /> commissary is discontinued. the permit holder must notify the EHD. Failure'to notify this office may result in permit <br /> revocation and penalties. n <br /> Signature / �c��— Date <br /> Commissary Nam any VIS <br /> f <br /> Address I + Bus. Phone <br /> City Zip _Owner(OperatorsdC&K <br /> MOM <br /> Check all appropriate services provided: - <br /> �W water disposal 2--3- moanment sink fflEElectrical hook-ups <br /> Solid waste disposal Food preparation 'oilet and handwashing <br /> t <br /> Hot Cold wafer for cleaning l3 Store refrigerated food Potable water <br /> e dry food/suppli s Overnich! parking Mole wash <br /> / <br /> ���if�.iy nerEDy Slate?Rai Ih@.Tifiormation i have provided is current,true and <br /> v <br /> carred to the best of my krowleece.and meets the Caromie Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement. or i," this agreement is modified or cancelled, the <br /> commissary o r 211 n ifi!ih HD immediaieiy. <br /> Signature Date 2�_ <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health 8 Safely Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> RENS Signature Date <br /> 1868 E. Haze!tor,A"'CriueCc!!'.Orric' 9J l._ T 209 4 68-342 F 239 1 -Ol 38 dvwvSi^y[A/.J'y:eni. <br />