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SAN JOAQUIN <br />-COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name PI--c11-1,A. y ]_Tc_e e „4 Lic. Plate # <br />Owner/Operator Name 47t) .1/ 07, <br />Business Mailing Address 0,2L,) rsA j>/ e , City c-L-ho y? State 64-Zip Ph.,907- VG? 7W-gt. PhO9 2O 7rw-- EYM )402_0 ir---idzhereby state that the above information is current, true and correct to <br />the best 6f my knowl dge and agree to utilde 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 • - • . -s. <br />Oir---tOr - Signature .00-0" <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Check all appropriate services provided: <br />0-Wastewater disposal La 3-compartment sink ur Electrical hook-ups <br />rif Solid waste disposal LI Food preparation qr Toilet and handwashing <br />EX Hot & Cold water for cleaning 1:f Store refrigerated food p(Potable water <br />O Store dry food/supplies Overnight parking pr. Vehicle wash 1/(i i-e/i -111(74/P , hereby state that the information I have provided is current, true and <br />correct to the best of my owledge, 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 HD ediately. <br />Signature . Date <br />To be completed by the HEALTH jurisdiction outside of 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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />Da te <br />61,127 /46,/ j7 I <br />Address 13 0/Iccra,1.4h ,It Bus. Phone <br />City 61) Zip frivd Owner/Operator <br />FA#