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JUAUUIN Environmental Health Department <br />—COU NT Y-- <br />Greatness yrows here. <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 />1. To be completed by APPLICANT <br />Business Name 1os.C.05 ( tcc extci. Lic. Plate # .g9 <br />Owner/Operator Name /72c7/7/Mi Ida ni a 5 <br />Business Mailing Address 77 51 6 Ma i )1 51 . <br />City .1-rt..tii-e.ifl- Stateoa Zip 957.625 Bus. Ph.Zai2.11? 5Y5k Alt. Ph. -)/-3i rin, f>ocil) <br />I, 42M:1e( Zia nia5 , 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 m t notify the EHD. Failure to notify this office may result in permit <br />revocation and lties./1 I <br />1., Signature. 70ML/./ I /d44€11 Date <br />3-compartment sink <br /> 13 Electrical hook-ups <br />Food preparation <br /> O Toilet and handwashing <br />Store refrigerated food <br /> O Potable water <br />Overnight parking <br /> O Vehicle wash <br />I, kaki <br />Outiide 'Of ..$an JOaquin Co:1 <br />The commissary is located in <br />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 />Date <br />REHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 l www.sigov.orgfehd <br />Commissary Name Puhkc,.. ,S4c ya66 <br />Address iWO W 014kirr,oriy <br />City 9zw-tfA-orN_ Zip 95 2 z) <br />Check all appropriate services provided: <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />FA# <br />Bus. Phone ---2-09 qz/ry 59 <br />Owner/Operator/-1VrYyl frhAd Pabii6 5/0A14-0 <br />, 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 own all noti the EHD immediately. <br />Signature <br />Date <br />CI Wastewater disposal <br />1:1 Solid waste disposal <br />Hot & Cold water for cleaning <br />CI Store dry food/supplies <br />p fLo s 8100