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SAN"'JOAQUIN Environmental Health Department <br /> COUNTY- <br /> -_ - <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. Ta te:completed:b /APPLICANT //v/d� q <br /> Business Name l�6->-L Lic. Plate#!J� /�� / ,?, <br /> Owner/Operator Name aAta— <br /> Business Mailing Address <br /> Ci State64_Zip t o5 Bus. PQW- F f - `'V/ AIL Ph. <br /> I, Iv/O)ql hereby state that the above information is current,_tme 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 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 andl a s <br /> Signature Date <br /> 2.To be completed bCOMMISSARY OWNEWOPERATOR <br /> Commissarry Name LA FA# <br /> Address 10100 Av la U&v, Bus. Phoney poci - L1 G115 70 <br /> City 0 0C'Ie�kn Zip SIS Zo5 Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal U/3-compartment sink MEI -cal hook-ups <br /> eolid waste disposal 0 Food preparation T let and handwashing <br /> �+ Hot&Cold water for deaning 0 Store refrigerated food �al le water <br /> C2 pre dry food/ plies �YOvemight parking Vehicle 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 comply with the con s of this agreement, or if this agreement is modified or cancelled, the <br /> commissa own r shall notify D immediately. <br /> Signature Date <br /> 3. To completed by the ENV HEALTH jurisdiction outside ofS.an.Joa uin 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, Carrfomia 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov-org/ehd — <br />