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QUIN <br /> .r= SAN:J0A0UIN Environmental Health Department <br /> r ._ —COUNTY— <br /> SI:, ?rt° Grectness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t 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 3 Tr>k�c <br /> Business Name Lic. Plate# 7b " A rn <br /> Owner/Operator Name J-t A R 1 Z' If Gr N UM 4AI 9W �� I g <br /> Business Mailing Address 5- 660 RQ? R US,S2 'DR Z t <br /> City ' 10 alt State c o Zip4S�Bus. Ph.k #AU 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 penall ies. <br /> Signature H ckr q WQ 17 Date I L0 d <br /> 2. To be com • leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ) A TP Vto 951" $ ;S q VWi FA# <br /> Address 3-117 mi',M E I-7 jl� 11� Bus. Phone :�<et— QOAr— 1'7 W 4 <br /> city S ImL�naAl Zip ...CA_ Owner/Operator <br /> Check all appropriate services provided: <br /> ® Wastewater disposal 0 3-compartment sink electrical hook-ups N <br /> w <br /> 0 Solid waste disposal O Food preparation o- et and handwashing 00 � <br /> ® Hot & Cold water for cleaning M�5tore refrigerated food p Potable water 0 N Z <br /> E3 Store dry food/supplies gKvernight parking p Vehicle wash q m C) <br /> I, hereby state that the information I have provided is current, true and Z Z n <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility 0 M M <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the D X <br /> commissary owner shall notify the EHD immediately. co D <br /> Signature .1„�/ , ` .�c,` .� Date m 0 <br /> D <br /> l /� R ^�'� <br /> 3. Tobe corn leted by the ENV HEALTH jurisdiction outQW-f 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 />