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NJOAQUIN <br />—COU NTY---- <br />:1L,' 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 />1. To be completed by APPLICANT <br />1-NP5z-3 Lic. Plate # <br />Owner/Operator Name -:.1,-ive...,4-0 Ciri-4 -2_ ( 5r C.i 0( ( i'l -- <br />Business Mailing Address 2q 03 iv . <br />City ,fr-t_KK,,ff )1(\ State04-Zip 6/AOC-Bus. Ph.2C7-7/5—Lii 03 Alt. Ph. <br />1, ----riVt-VI-v Cvvz-- , 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, th ermit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and pe les. <br />Signature <br />2. o'be coMpleted by _COMMISSARY -OWNER/OPERATOR <br />Commissary Name OGCs(\Vo-CL-3 CrA, FM <br />Address (07,c--).SCC ccv\Ne A-k0 cT Bus. Phonk 2-Lt —E)S 3 4. <br />City (.5.)& , Zip P.S-Z,L4-0 Owner/Operator letkCC,,C0(l.00 /1\1001 ricfoct <br />Check all appropriate services provided: <br />pl\Wastewater disposal <br />)Cf Solid waste disposal <br />,It(Hot & Cold water for cleaning <br />Store dry food/supplies <br />kst 3-compartment sink <br />Food preparation <br />ID Store refrigerated food <br />)3( Overnight parking <br />17( Electrical hook-ups <br />.Toilet and handwashing <br />Potable water <br />OrVehicle wash <br />Cocx\m-Aciii.i , hereby state that the information I have provided is current, true and <br />correct to the best ofiny 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 noy the EHD immediately. <br />Signature Date 041 110IZ,C( <br />t15ebO6ifileted.bY the ENV:HEAITIffjunsdictibfibutèide ofSaniouinCo. <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 END if the status of their operating permit changes. <br />REHS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />clo'H <br />Business Name ire9 adle do S <br />- Date