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EnVironrnental Health Department <br />P12-roL-ts Los( <br />Jo be completed by APPLICANT i''";;7744W): <br />Igo complote 50000 3. COMMISSARY AGREEMENT <br />obile und Facty I, Caterer <br />,n <br /> located otitside of San Joaquin Courtly e • <br />, . Nurnin u: Complete sections 1 and 2. <br />e-• <br />If your ct <br />Plat # <br />/. <br />Business Name <br />SAN ,JOAQUIN <br />N NY <br />/- <br />Safety Code: and San Joaquin County Environmental H <br />Health Department (EHD) requirements. If the use of the the best of my knowledge and agree to utilize my approved commissary in acc,ordance with California Health & <br />commissary is discontinued. the Permit holder must notify the EHD. Failure to notify this office may result in perrnit <br />revocation and penalties. . <br />• <br />Signature <br />2. To 'Cl e).VV NINAIS r• _ REIVOOR'-' <br />FAtr_0_02 <br />"Electrical hook-ups <br />Toilet and handwashing <br />IP/Potable water <br />U:Kehicle wash <br />Store dry <br />, hereby state that the information I have provided is current. true and <br />correct to the best <br />of my knowledge and meets the California Health & Safety Code requirements. If the food facility <br />operator <br />fails to comply with the conditions of this agreement, or if this agreement is modified or caleelled, the <br />commissary own hall noJifve EHD immediately. <br />Signature <br />3. To bmpIete&bMtifle ENV ME Tii4wisiiktionioutsidwaSaggoaq_iin eqj <br />The commissary is located in County. The above food lacility meets the <br />commissary requirements in California Health & Safety Code. The above checked serviLtn: available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />RENS Signature <br /> <br />Date <br /> <br />1868 E Hazeitun Avenue I Stockton, California 95205 I T 209468-34201 F 209 464-0138 www.sigov.orglehd <br />MA .f ) 4 d S. <br />Owner/Operator Name <br />Business Mailing Address ;,7 <br />t. <br />. hereby state that the above information is current. true and correct to '*-State_CA_Zi14.42....._Bus. Ph./ <br />2 41 <br />).4cyL2.2.6 <br />Alt. Ph <br />Check all appropriate services provided: <br />"Wastewater disposal <br />.Solid waste disposaW-7- <br />. water for cleaning <br />0 food/supplies <br />Bus. Phone <br />City_44:13c42_.-Zip_16_3.-3Q_Owner/Operator__ <br /> A,=_F <br />Cornmissary Name_ Li Akh.r.o. <br />Address <br />0 3-cometrnent sink <br />CI Food preparation <br />0 Store refrigerated food <br />SI 'Overnight parking <br />Date4 1 57.