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SANAOAQUIN Environmental Health Department <br /> —COUNTY— <br /> - ��_��• �i'Pv t!1r Ss �/fiwi : PrP. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer , <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be com feted by APPLICANT = U <br /> Business Name nn c. late# o 3 <br /> 81 <br /> Owner/Operator Name (. 7 t <br /> Business Mailing Addres ���� ) � <br /> City State ZipS .11 Bus. Ph,�1q �X It. Ph. <br /> 1, AAA hereby state that the above information is current,true and correct to <br /> the best of my krfowledg6 and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin Coun Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is disconti ed,,th ertnit h der ust notify the EHD. Failure to notify this office may result in permit <br /> revocation and pena 'es. f <br /> Signature �.r Date fo h <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR.. i <br /> Commissary Nam �l <br /> Address N r : Bus. Phone w 2 <br /> City LZip�SOwner/Operator VA f v <br /> Wk all appropriate services provided: <br /> astewater disposal . Cd'"3-compartment sink electrical hook-ups <br /> Er-Solid waste disposal QlFood preparation ErToilet and handwashing <br /> CV of& Cold water for cleaning Q St re refrigerated food U'Potable water <br /> Store dry food/supplies Ovemigbtparking ehicle wash <br /> I, ,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 to ly with the conditions of this agreement, o if this agreement is modifi or cancelled, the <br /> commissa o sh o HD' ediatel . r <br /> Signaturery �e����p/ Date �J <br /> 3.-To be'dom leted b ,the ENV.HEALTH jurisdiction outside of San°Joa 0h .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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />