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sAN IOAOUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility f Caterer <br /> Comp to asc&o,s f and 2, rr your camaVssary 1s located outside 0 San Joewin County also complow section a <br /> 1. To be completed_by APPLICANT <br /> Business tame �,- y li n N i'[:1,'(i r C1/l] ��E'AJC.Plats# <br /> Omned0perator Name �'�1aL�� 4 U Ile-'1_ <br /> Business Mailing Address.-L-2 62 Al f 1v f 1 - <br /> City%r_t.�f 1•j Stabs rtp Bus.Ph. :3C I .;2 3 :a YAIL Ph. <br /> t, hereby state that the abrnre Infarmadon is currarft,true and ccrrect to <br /> tho Gest of my knowledge and agree to utilize my approved commissary In accordance whit Calltornia Health& <br /> Safety Cods, enc San loaeuln County Environmental Health Departmerd(EHD)requirements. If the use Of the <br /> mmmissay Is discunttnuid the permit holder must notify the EHD. Falure to nobly this office may result in permit <br /> revocation and penalties. d <br /> Signature.'ti. f -I'-•t•7.�.%�" Data <br /> 12.To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Nameu '-< f: FA# <br /> Address <br /> 7� <br /> _Zips`,/_Owner/Operator <br /> Check all appropriate serrires prop^ded; <br /> t WasteH•ater dlsoos-a; '5L 3-compartment sink M Electrcal hook-ups <br /> Solid waste disposal U. Food preparation 7-'Tollet and handwashing ._ <br /> ® Hot&Cold'Water for cleaning 1s Stor6 refrigerated food �"Potable water <br /> 0 Store dry foadisupplies LL Ovemight par-king tU' _Vehicle viash <br /> — •__-L .;- > •hereby state lnat the information I have pro•M8d is current,true and <br /> correct to the beat of my xrcnvladga,and meets fhe Call,ernia Health&Safety Code requirements. If the ood faaity <br /> oporatnr falls to conVly with the condibo`ns or this Agreement, or if this agreement Is modiflcd or canceMod, the <br /> oammisaery ormer sh80po*thg•EHD immediately. <br /> Signature <br /> Date l "/ <br /> C--�_ �- _ <br /> 3. T <br /> mobe cofeted b file 'HEALTH �ut risdictian outside of son Joagtain Co. <br /> The corrrn►ssary is located in Counts. The above food facility meets the <br /> commssary requirements in Callfamla Health 6 Safely Code. The above.checked servicas are available at the <br /> above ccxnmissary. Piea`e notlry EHb if tie status of their opc:allrig petratit Changes- <br /> REPS 5lgnature <br /> Date <br /> 1862 E_HazBU-)AvenLm I Siackton,California 952G5 1 T 209468-3420i F 209464-0138 I�����v,sjgov.org;erd <br />