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Business Name <br />Owner/Operator Name <br />SAN JOAQUIN <br /> <br />Eff:©rimeal HiDth [c m e <br />— COU NTY-- <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 APPLI ANT <br /> Lic. Plate # 9 Z-73 <br />Business Mailing Address b() /DY----= <br />City- 7 State 0-4 Zip 53 kBus. Ph. 9-0- )/-7,)( Alt. Ph. .1/72- 0)-2(1'((' j'A <br />5 , hereby state that the above information is current, true and correct to <br />the best of my knowledge and a ree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San ibaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinfied, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation an enalti <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 1 ci,y 1-5Z4A FA# <br />Address 7 5 5- /-/- ./1//r p' Bus. Phone (i z71 <br />City ..-61/` Zip 9)Y c Owner/Operator A <br />Check all appropriate services provided: <br />Wastewater disposal 01 3-compartment sink "§r Electrical hook-ups <br />la" Solid waste disposal 0 Food preparation 17;le -Toilet and handwashing <br />ISr Hot & Cold water for cleaning 0 Store refrigerated food pr'Potable water <br />0 Store dry food/supplies ''Overnight parking Vehicle wash <br />I, 1)7.; 7,2„ , hereby state that the information I have provided is current, true and <br />correct to the best of my knowlfrete, 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 potify t EHD immediately. <br />C Signature Date <br />To be completed by the 861)1 EALTH jurisdiction 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 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 />PR sL-i 11 33 <br /> <br />Date <br />