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<' SAN.JQAQUIN Environmental Health Department <br /> COUNTY— <br /> ' <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 Sur Ay Qzton Lic.Plate# <br /> Owner/Operator Name v\We_ 20,3\ V\Qahe_{ <br /> Business Mailing Address ILLS e, 14c"-6cwa �a,.t <br /> City `JAc. v% State(-a Zip S� Bus. Ph. 2a�-7�/7 63�3AIt. Ph. <br /> hereby state that the above information is current,true and correct to <br /> the best of my know) ge 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 /> commissa s dis tined,the permit holder ust notify the EHD. Failure to notify this office may result in permit <br /> revocation nd persalt s. <br /> Sig natur Date R q Z I <br /> F-2—. com Ieted by C-OMN jSSARY R/OPERATOR <br /> Commissary Nam \ �l <br /> Address �J Bus. Phone W I� <br /> City L Zip Owner/Operator Via d C) f v <br /> Cheylc all appropriate services provided:13/Wastewater disposal U-3-compartment sink electrical hook-ups <br /> Er'solid waste disposal Food preparation E Toilet and handwashing <br /> E of& Cold water for cleaning O St re refrigerated food CrPotable water <br /> El"Store dry food/supplies Overnight parking ehicle wash <br /> I, Sae h 11.t'&P'', , 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, of if this agreement is modified or cancelled, the <br /> commissary ow sh otify HD '° ediately. <br /> Signature Date <br /> 32-76 be completed by-the ENV,HEALTH jurisdiction outside of.San' Joa46ih Clo, : <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 1 F 209 464-0138 1 www.sjgov.orq/ehd <br />