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SANAMIN <br />()LINTY - <br />Grefinetit <br />Environmentat Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />Complete sectiona I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name <br />Owner/Operator Name <br />Business Ma. ing Address <br />City <br />seass. <br />eos n-- <br />thr <br />s <br />Zip Ctc2.1CIIF:us. Ph <br />tliftd eta <br />Lic. Plate # 6 g <br />1252__ <br />L owic <br />t. Ph. <br /> , hereby state hat 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 Heath Department (END) requirements. If the use of the <br />commissary is discontinued, permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and c es. <br />Signature <br />_PALO 4“. <br />Commissary Name <br />Addr s 13 <br />City S C1 <br />Check all appropriate services provided: <br />Date <br />us. Phone (20 2- <br />Owner/Operator Zip <br />k'Wastewater disposal <br />rrgrTlid waste disposal <br />& Cold water for cleaning <br />a-51:5-ne dry food/supplies <br />.-compartment sink <br />aiood preparation <br />Store refrigerated food <br />..a.--6verniont parking <br />ri4lectrical hook-ups <br />CrToilet and handwashing <br />Potable water <br />ehicle 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 mply with the conditions of this agreement; or if this agreement is modifi or cancelled, the <br />II no 'fy the ,D immediately <br />- <br />The 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 />18618 F H7.37Pitnn IP I R.trwletnn Cgc!nc t °.-Infettbrit ran lint rgiet-N flint. &Pa ri . I In .t oft. <br />commissary o <br />Signature <br />sepai€