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`r OEnvironmental!tHealth Depar;tmen'i <br /> - C O U N T Y--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ,,,.; Caterer <br /> Complete sections 1 and 2. if your commissary is focated outside of San Joaquin County also complete section 3. <br /> 1 . To be completed by APPLICANT <br /> Business NameNar S �� /' late## s �/ V o ! <br /> Owner/Operator Name La <br /> Business Mailing Address '�)"75 E S ��� <br /> City State-LAZip �� Bus. Ph. Alt. Ph.(`,/ <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, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinue the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. _ <br /> Signature Date <br /> 2. To be com le'ted by COMMISSARY OWNER/OPERATOR <br /> j <br /> Commissary Name War S '(MS C G{5 FA# <br /> Address '�-�` �� E— . k Bus. Phone 00q) <br /> City 5 n Zip g'772,6^ Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink Electrical hook-ups <br /> Solid waste disposal i Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> ;Store dry food/supplies Overnight parking -7 Vehicle wash <br /> [, hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails tocomk with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ownerI notify the EHR 1r, d' 1 ! <br /> Signature Date ~' i Z <br /> 3. To be completed by the EN 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 /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 € F 209 464-0138 I www.sigov.org/ehcl <br />