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Stani <br /> = S A NO A Q U 1 N Environmental Health <br /> —_COU NTY <br /> :,, '' Greotness yr-otvs here. <br /> MARY-KATE COOK <br /> COMMISSARY AGREEMENT ScEnwronmentalHealth <br /> Specialist <br /> Mobile Food Facility + Caterer ENVIRONMENTAL RESOURCES <br /> Environmental Health Division <br /> 3800 Cornucopia Way,Suite C <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also comf Modesto,CA 95358-9494 <br /> Direct:(209)525-6713 <br /> 1. To be completed by APPLICANT I Main:(209)525-6700 <br /> Cell:(209)505-7388 <br /> figCM: Nyyl�_ n Fax:(2oo @en <br /> 6774 <br /> Business Name Ic.Plate# �U � Email:mk mkcookCa�envres ora <br /> aunty com <br /> Owner/Operator Name l - r <br /> Business Mailing Address Z-*- Lr�✓o�t�, d L,c/Ct <br /> City_ fi C� StateAZip 95374 Bus. Ph. (offO- 53A- 8ygy Alt. Ph. <br /> 1)L'Q gorri�Q 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 ' S. <br /> Signatu e Date / <br /> 2. To be completed by COMMIS <br /> S <br /> ARY OWNEWOPERATOR <br /> Commissary Name &Q Cm'SQr iC �o FA# <br /> Address 21 1 S. � �� i'ee Bus. Phone (ZM)33 15�366 <br /> City P od e 5},r, Zip X1535) Owner/Operator S�"Og p C <br /> Check all appropriate services provided: <br /> M Wastewater disposal IN 3-compartment sink 13 Electrical hook-ups <br /> 0 Solid waste disposal M Food preparation 0, Toilet and handwashing <br /> W Hot & Cold water for cleaning 0 Store refrigerated food 12 Potable water- <br /> 0 Store dry food/supplies M Overnight parking J2 Vehicle wash <br /> I, Marls Lui5-C(Va , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, 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 EHD immediately. <br /> Signature Date /OZ 12.117 7 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa u)n 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 /> 1 <br />