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heF, <br />ronrrtental Health <br />COMMISSARY AGREEMENT <br />Complete sections Mobile Food Facility ♦ Caterer <br />fand2. t/yourcommissar iy <br />1 • Tti 6 y located outside o1 San Josqu6r county <br />e comnlp+oa �... �_. _ <br />Business Nam, <br />Owner/Operator Name <br />Business Mailing Address 2•_lf % p p <br />,IZip I, Ph. <br />t <br />I,he best of n l 5 hereby state that the above information is r <br />My knowledge and agree to utilize my approved commissary In eccordariG <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requid <br />commissary is discontinued, the permit holder mu"otifythe EHD, Failure to notify this, <br />revocation and penallA. <br />To <br />Commissary <br />Check all appropriate services provided: k} , <br />0 wastewater disposal O 3 -compartment sink or ElectnczPhook-up <br />17 Solid waste disposal 0 Food preparation 1A Toilet and har dw� <br />10 Hot & Cold water for cleaning O Store refrigerated food QI Potable water <br />O Store dry food/supplies I$ Overnight parking P Vehicle wash <br />�r'�� y y/NeaA� hereby state that the information 1 have provided is curre <br />correct to the best ofmy k ledge, and meets the Calffomia Health & Safety Code requirements, it the <br />operator fails to comply with the conditions of this agreement, or If this agreement is modified or ce <br />-_itside of San <br />The commissary is located in County. The above food <br />commissary requirements in Cat' mia Health 8 Safe = <br />ty Cc. _. -e checked service <br />above commissary. Please notify END if the status of th= , - . , it changes. <br />EHS Signature <br />Avenue I Stod ton, Cafe: :. ; _ .T T 209 466-3420 i F <br />