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. ^ . . . <br /> - ~ A N~oUO UUN Environmental Health Department <br /> --COUNTY-- <br /> G'ootness grcviS here. <br /> ������N�U������� ��U���������U�^� <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + caterer <br /> Complete sections Y and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT —777�1 <br /> { <br /> Business Name io. Plate � � <br /> D Ph � —' <br /> 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 & <br /> Safety Code, and San Joaquin County Envir tai Health Department (EHD) requirements. If the use of the <br /> continued,the permit h must notify the EHD. Failure to notify this office may result in permit <br /> commissary is <br /> 12. To be complete(d by COMMISSARY OWNER/OPERATOR <br /> C--A <br /> Auo/eu ., Phone <br /> `(/} <br /> ^/ <br /> Check all appropriate servicesprovided: <br /> ~�/VVaetovvoterdiopooa| pa�n�antmink �� Beothom\ hook-UPS <br /> ` 8o|id vv�ote disposal Food preparation tXToihd and handvvaohing <br /> ��` -- <br /> mi "ot & Co|dvvaterfordenning 13 Store refrigerated food M Potable water <br /> E3 Store dryfood/oupp|iao fflJvsrnight parking EfVehiola wash <br /> I hereby state that the information | have provided io current, true and <br /> correct to the best of myAnowledge, e|' the California Health&Safety Code requirements. |f the food facility <br /> operator fails to comply with the conditions of this agnoement, or if this agreement is modified or cancelled, the <br /> commissary owner shall noti�,-the HD immediately. <br /> County.Signature Date <br /> F�.7�To be 66m-plleted by the ENV HEALTH judsdiction ouWde of-San Joaquin Co. <br /> The is located in Theb�e �d ��U� m�� �e <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHOif the status uf their operating permit changes. <br /> REHSSignotuDate <br /> 1DG8E. Haze|hon Avenue I Stockton, California Q52O51 T 209468-34201 F 209464'0138 1vmxwv.sjgov.org/ohd <br />