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SAN 10AQUIN Environmental Health Department <br /> —COUNTY— <br /> •r GreotneSs gr.t.3 h.er< <br /> REVD" 'ANNED <br /> JAN ii o 2024 COMMISSARY AGREEMENT <br /> CCEH Mobile Food Facility♦ Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of Sari Joaquin County also complete section 3. <br /> 1.To be completed by APPLICANT <br /> Business Name �.._'i 'i� 1 i, =�'' �:���Cc%�� c te <br /> Owner/Operator Name ) nr;'�;.;; <br /> Business Mailing Address co,, X-L_r7�i G o { / <br /> City CLO!_1e4 - > State/_.r Zip Gi i.;f-i,, Bus. Ph. ={ '2 <'.'r c. j(AIt. Ph. <br /> 1,1 t/rhl> (•'rl r Z c i�� ) i i.� 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 8 <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 END. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature -- --Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name `f (_`r e,t It i t , -t; FA# <br /> Address -t i L t, Bus. Phone <br /> t <br /> City - Zip ' -Owner/Operator-- <br /> Check <br /> Owner/Operator—Check all appropriate services provided: <br /> a Wastewater disposal a3-compartment sink 0-Electrical hook-ups <br /> _Q-Solid waste disposal 0-Food preparation G Toilet and handwashing <br /> ET Hot&Cold water for cleaning !?Store refrigerated food 48"Potable water <br /> Z Store dry food/supplies B Overnight parking O'Vehicle wash <br /> I,_`rt[,,-_ '-"C.)1.r I.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- - .—rte-S'c '.i,l t_Lc-<. -----Date / be h-Z-'. <br /> 3.To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in_ CA7y1" (ASS County. The above food facility meets the <br /> commissary requirements in CalHornla 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 /> C 11 l <br /> REHS Signature___ <br /> ignatureI lel l� <br /> 1868 E.Hazelton Avenue I tockton,Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov org;ehd <br />