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SAN <br /> JDA <br /> ' <br /> �� � S �� �� UM� <br /> . COUNTv <br /> 6�������U��� � �� ���k�����0���[�^� <br /> ���vo��o�un����J�i�� U x=o��������ono��on u <br /> ' M(JhUe FoOdF3Cii'tVv,\ Caterer <br /> Complete sections Iand 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Owner/Operator Name <br /> Business Mailing Address <br /> |. . <br /> hereby state that the above information is current, true and correct to <br /> the best ofmyknowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHO) requirements. If the use of the <br /> commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may nyau|t in permit <br /> revocation and penalties. <br /> /- <br /> Da <br /> Signature <br /> 2. To be completed by qOWSSARY OWNER/OPERATOR <br /> SS Bus.' Phone <br /> Addre <br /> Cit Zi A Ownier/Operator <br /> Check all appropriate services provided: <br /> �� <br /> )l Wastewater disposal .'� 3'n0nnp8rtrneOtSink ��^= Electrical hook-ups <br /> Solid waste disposal !' . Food preparation �41 Toilet and h8ndm/@Shing <br /> Hot & Cold water for C|e8OiDg i ^ S0D[g refrigerated fOOU DA Potable vv8tR[ <br /> ' Store dry food/SUpplies ^i /\ <br /> vernight parking . Vehicle wash <br /> . hereby state that the information | have provided is ourrent, true and <br /> correct to the best of my knowledge, &Safety Cd f the food facility <br /> operator fails te-comply with the c itions of this a ireement, or if this agreement is modified or cancelled, the <br /> commis notify <br /> y HD immediate <br /> sat t_ <br /> Signature Date <br /> To be a IV HEALTHjurisdiction outside of San Joaquin Co. <br /> The commissary in located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked sen/iuoe are available at the <br /> above commissary. Please notify EHD if the status nftheir operating permit changes. <br /> REHS Signature -Date ______ <br />