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LIc 1-} V S1 tan* <br /> 1. SAK:.J 0A0U IN Environmental Health <br /> r COUNTY-- <br /> -:. h �� OD� � S ii <br /> y <br /> Greotness gro,vs ere. <br /> - -- <br /> - -- MARY-KATE COO <br /> senior Environmental Health <br /> COMMISSARY AGREEMENT Specialist <br /> Mobile Food Facility ENVIRONMENTAL RESOURCES Caterer 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 come 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 /> n Fax:(209)525-6774 <br /> Business Name <br /> "�g'cs A;k N'1a>Inktic.Plate# U Email:mkcook@envres oro <br /> �tancounty com <br /> OwnerlOperator Name '1 P <br /> Business Mailing Address #?- 6)^oria- D <br /> City 1-0 StateL_Zip q53,z4 Bus. Ph. 65 O- 336?- 8yq y Alt. Ph. <br /> hereby state that the above information is current,true and correct to <br /> the best of y 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 <br /> Signatu a Date 10 / <br /> 2. To be completed leted b COMMISSARY OWNER/®PERATOR <br /> CommissaryName �Q Com;sn r ►a Mc�'A5 0 FA# <br /> Address <br /> // �Z I 1 S. 41, S) r'ee 1- Bus. Phone (ZOa)33 SS-36ro 3 <br /> City /vl o(1 e S Iv Zip ci 535) Owner/Operator P <br /> Check all appropriate services provided: <br /> M Wastewater disposal 12 3-compartment sink M Electrical hook-ups <br /> Q Solid waste disposal 0 Food preparation Toilet and handwashing <br /> R Hot & Cold water for cleaning 22 Store refrigerated food Potable water <br /> til Store dry food/supplies M Overnight parking J3 Vehicle wash <br /> I, Mark Luis-Cn),a , 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 /U/1am-.27-7 <br /> 3. To be completed by the ENV HEALTHjurisdction..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 /> REHS SignatureDate 10 {�-� ITZ <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 f T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> S <br />