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r ; SAN.JOAQUIN Environmental Health L <br /> I --COUNTY— , fltY <br /> Greolness grows here. <br /> T <br /> cooK <br /> MARY Kpro meatal Health <br /> COMMISSARY AGREEMENT SP .8 t Wisjon <br /> Mobile Food Facility ♦ Caterer EMIVroonmenal a Nta�sudaG <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete se 33oooi5�n�g5b�93 4 <br /> �1L35 <br /> ode '52.5-fil0o <br /> 1. To be com let6d,by APPLICANT vajoLr8d09)o9)505,114 <br /> 33a <br /> �4CQS � w1a NLI. Vt t"KhV)kQ�ic. Plate# l IU I� /S f;t ay" k o <br /> Business Name x <br /> Owner/Operator Name 1 <br /> Business Mailing Address -4- <br /> City '-F��StateLA-Zip_953 Bus. Ph. (c5p- 33y- 8y4Y Alt. Ph. <br /> I, ncge Barrti ct hereby state that the above information is current,true and correctto <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 <br /> Signatu a Date / <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName LQ Coma SQr is FA# <br /> Address 12-1 t _5. �41, 5>' ree P Bus. Phone (Zog)33%-36A'� <br /> City PbAes-Fn Zip 95351 Owner/Operatorrnlr/ 3>< eyyP �.y„ss <br /> Check all appropriate services provided: <br /> M Wastewater disposal 19 3-compartment sink M Electrical hook-ups <br /> 10 Solid waste disposal ® Food preparation I3' Toilet and handwashing <br /> IN Hot & Cold water for cleaning 0 Store refrigerated food 12 Potable water <br /> 0 Store dry food/supplies M Overnight parking )® Vehicle wash <br /> I, Mark Zui5-t^ftrZ- , 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 svE�- Date /U//-,1-12 7 <br /> 3. To be completedby the ENV HEALTH jurisdiction outside of,San Joa uin 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 <br /> LEHD if the status of their operating permit changes. <br /> REHS SignatureDate <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />