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.r - s• S A N J QA Q U I N Environmental Health Department <br /> ti Lnl;�4 —COtJNTY— <br /> , <br /> °+•,,.,p��' Greotness grows here. <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 7n (n � jo :T-U f v 2r r Lic. Plate# y SS H I ,9 <br /> Owner/Operator Name Taste C,cma-7 <br /> Business Mailing Address 31LoH 1 '1 nnlear Ar e=-_ <br /> Ci Mt1o1PC+t> State ri <br /> City Zip 535 Bus. Ph. ( Oa S ` S AIt. Ph.(70G� 5 9.l ` Y 6 d <br /> hereby state that the above information is current, true and correct to <br /> thebest'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 discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation=penalties. 4 <br /> SignatureJ(J'::�P_ Date ci <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> e <br /> CommissaryName Za /!omrsacra M eSEO FA# <br /> Address I a 11 S. V k 54-c4re l' Bus. Phone(aoq') 331-36G 3 <br /> City 'YedeAo zip 45351 Owner/Operator Cold 5+04-43t cv, ..rssay, Inc. <br /> Check all appropriate services provided: <br /> Wastewater disposal PJ'3-compartment sink GrElectrical hook-ups <br /> Ef'Solid waste disposal good preparation . Wfo let and handwashing <br /> LIHot & Cold water for cleaning CYStStore refrigerated food CF"Potable water <br /> [°f Store dry food/supplies GS Overnight parking C�'vehicle wash <br /> I, /cock C"is -4_"Nt e , 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 comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> Signature �� Date V2112 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San JoacluihnCo. <br /> The commissary is located in ghCV ;1,ai e,S a County. The above food facility meets the <br /> commissary requirements in Cali mia Health & Safety Code. The above checked services are available at the <br /> above commissapy-'PfeRpe noti ` i be statusof their operating permit changes. <br /> REHS Signatur Date <br /> 1868 E. Hazelton Avenue I Siockto ,'Califor 952051 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />