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S A N l0 AQ U I N Environmental Health Department <br /> U N T Y___- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility # Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name Sury�p Lic. Plate# <br /> Owner/Operator Namee \X o$&)N. <br /> Business Mailing Address IyS e— 14c%XrA:vka t�'-j5cw <br /> city SAcKA y\ State(ZAAZip SZ-OBus. Ph. 2o03g3AIt. Ph. <br /> I,_��66\� w0.N ,hereby state that the above information is current,true and correct to <br /> the best of my knowledg and agree to utilize my approved commissary in accordance with Cal'rfomia Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissa s dis timed,the permit holder ust notify the EHD. Failure to notify this office may result in permit <br /> revocation nd penalt <br /> Signatur Date $ • q• Z I <br /> 2. ; corn leted by C WJINRY R/OPERATOR <br /> Commissary Nam <br /> !i <br /> Address h 1 Bus. Phone �C f� <br /> City � <br /> ( _Zp�_Owner/Operator V� 1� w ► v <br /> Check all appropriate services provided: <br /> Wastewater disposal 0-13-compartment sink 12'fleetrical hook-ups <br /> O Solid waste disposal Wood preparation 0"Toilet and handwashing <br /> O'Hot& Cold water for cleaning 0 St re refrigerated food MP�otable water <br /> ET Store dry food/supplies Ovemight parking 0-/ehjcle wash <br /> I, Saber !1 , hereby state that the information I have provided is current,true and <br /> correct to the best o y 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 modified or cancelled, the <br /> commissary ow sh otify HD' ediately. G (] <br /> Signature iY �Q! Date 1 f/ <br /> 3 Oom eted by-the ENV HEALTH jurisdiction outside of San Joaquin Go. <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, Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />