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rA0D23y34 <br /> SAW <br /> - -CourvTY-- --- <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 Yl`F ( nt l Lic. Plate# <br /> Owner/Operator Name O G GY t✓ <br /> Business Mailing Address o GtY� r,Uc- <br /> Ciif rCt StateLEZip U Bus. Ph. I d Alt. Ph. ` <br /> I, hereby state that 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 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 and penalties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name C4 C Ino, FA# <br /> Address 's Z (/filo S. jrpcor4- cmc Bus. Phone <br /> City S:6CZip f,C)tS Owner/Operator 91 Ar rj <br /> Check all appropriate services provided: <br /> ® Wastewater disposal W 3-compartment sink W Electrical hook-ups <br /> a Solid waste disposal -�" Food preparation U�t Toilet and handwashing <br /> W Hot& Cold water for cleaning Store refrigerated food V Potable water <br /> W Store dry food/supplies Overnight parking A�Vehicle wash <br /> 1, :2 ,'—S l.,�2 i 0 , hereby state that the information I have provided is current, true and <br /> correct to ihi 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 Z�jk /9? <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <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.org/ehd <br />