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&*t <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility caterer <br />Complete sections f and 2 Iff yourcommiswry is locaW outside of San Joaquin County el <br />F'1. To be com leted -by APPLIG. ANT <br />Business Name � Q�lr�' i Lic. Plate# <br />OwnerloperdWr Name <br />Business Mailing Addressj( <br />Ciry <br />rye <br />� psi <br />>�c�� S�tE�zp say Bus. PhPh <br />the best of my know) <br />X53- 53g�Aft Ph. �C19 �� �s ac4?o <br />hereby state that the above information is cvrtsnk..true and carred to <br />ge and agm to uto my approved commissary in accordance with California Health 8 <br />Safety Code, and San Joaquin County Environmental Health Depertwt (EHD) requirements. If ft use of the <br />commissary Is d1swnflnued, the permit holder must noUty the EHD. FaDure to notify this u- nm may result in peffntt <br />revocation and penqtqes,-.,/j��, - <br />Signature <br />Address <br />Cb <br />rOMINISSARY ((j)WNE-RIOPERATOR <br />bus. Phone <br />FA# <br />Check all appropriate services pro <br />9 op <br />Wastewater disposal <br />0 Solid waste disposall <br />000 <br />lioo�m <br />Hot & Cold water for cleaning <br />� <br />F> re dry food/supplies <br />wded'a. <br />200;0I <br />compartment sink <br />� FOWprep aration <br />Li <br />Stole reirigarated food <br />ical hook-ups <br />:IF <br />and ha ndwashing <br />Ovemigrn parking 9f Vehicle wash <br />A/I l�L 4r7 hereby s4ate that the information I have <br />correct to the best of my knowl ge, and meets the Caffomi <br />a Health x Win. �,.,�e .,�.Wded is current true and <br />Operator fails V comply with the=nditio <br />if <br />commissary owner shell notifyd;e EHD ir <br />Signature � It <br />ccz- <br />0 <br />:• _9 7 , <br />I WIF <br />1 i � <br />3. be corn leted b the ENV HEALTf-I <br />The commissary is located in <br />�Om1T1[SSBN rBauirAmsnt� <br />in r.,�.....�_..,..---urisdiction outside of Sari Joaquin Co <br />- ..�tf <br />���w, neaRn r� salary Code. The�- Thchecked1111,a6ave fond faaTdy meets ftabove oomm�ary� Please netlfy E?iD if the status oftlheiroperatlno �e ft cnan9ervices are available at the <br />aermes. <br />RENS SignatLwe <br />4F <br />Date <br />mob-= <br />} <br />