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_ <br /> Environmental <br /> Health Department[ ANJOANIN <br /> —CDUNTY — <br /> COMMUSSARY AGREEMENT <br /> Mobile Food F8cilitv+ C@tePer <br /> Complete sections Iand 2. /fyour commissary iulocated outside nf San Joaquin County also complete section 3. <br /> 11) <br /> Busines Mill Add <br /> Citya <br /> ["�/nv-/ W'D ITI I iop hereby state that the above information is current,true and correct to <br /> the best of mylkno�v_ledg� arid agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. |fthe use nfthe <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 /> Signotur �a� - <br /> Commissary NamP'4 11,6(t) Irl W <br /> Check all appropriate services provided: <br /> 0"VVastmwaterdispoSa| EPI~oompartmentuinb D ��|�ctrico| ho8k-Upa <br /> �� <br /> ��3 |id wastedisposal Ck'F d U 13"Toilet <br /> I U wate for | [3 Store refrigerated food E»15o+ob|avxater <br /> I CYVehidomash <br /> |' hereby state that the information | have provided incurrent,true and <br /> correct to the best of my-Rnowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator falls to com ly With the conditions of this agreement, or if this agreement is modifiee <br /> Signature 4� e!fzeZ0Q4 22 Pat <br /> The commissary inlocated 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 Oat <br /> 1858E. Hazelton Avenue I Stockton, California H52O51 T 209468'34301 F 2094O4-0138 1vvwwv. jgov.org/ehd <br />