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r . <br /> SANtJOAQUIN Environmental Health Department <br /> ` —COUNTY <br /> �,.;,.�,•_° Greu r,ess .;rows herr. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ® Caterer <br /> Complete sections 1 and 2. /f your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name Roc.lc&, 'Poo&h-5 �:9? L- LC— <br /> Owner/Operator /� <br /> Name l�l g'cr <br /> Business <br /> L01 VMailing Address jao-7� ti - �SGlWl�1� <br /> Cit y `1 '41 State} Zip So4,5_Home Bus. Ph. <br /> 1, G f!A , hereby state that the above information is current, true and correct <br /> to 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 disVies. <br /> , the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and i <br /> Signature Ako. C)Ul/I w Date av-aa-- <br /> 2. To be com le d by COMMISSARY OWNER/OPERATOR <br /> CommissaryName Ln l CNI"isaclia N1oks2 a FA# <br /> Address UAk S. Bus. Phone C7.Dq) d'�K-3663 <br /> City ok-'v zip 953,,51 Owner/Operator %elef 5fvcz>,ge Gmmisnt1nc. <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink Electrical hook-ups <br /> 4 Solid waste disposal 0 Food preparation IA Toilet and handwashing <br /> 1,at Hot & Coldwater for cleaning Store refrigerated food OI Potable water <br /> C1 Store dry food/supplies Overnight parking M Vehicle wash <br /> I, ma' I JiS rcya , hereby state that the information I have provided is current, true <br /> and correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food <br /> facility operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, <br /> the commissary owner shall notify the EHD immediately. <br /> Signature �tlACI.,✓'� Date ttl 11Al2 - <br /> 3. To be completed by the ENV HEALTH 'urisdict- <br /> . MMOKOEw mm OTC <br /> The commissary is located in 5—k a tJ I e LA uS a ' �' u & o a A z 5 <br /> commissary requirements in California Health & Safety Code. The o N o 0 3 z a <br /> above commissary. Please notify EHD if the status of their operating o N o U > m a' <br /> xu v 44 TN � 8 e? 3m <br /> REHS Signature _ A o m m m m'_O ,1 <br /> o T sW 20 <br /> 1868 E. Hazelton Avenue ckton, 'alifornia 95205 1 T 209 468-3 8 o w > o z <br /> �� n N <br />