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�A N 5 OAQ U I N nvironmental Health De;oarment <br /> COMMISSARY AGREEMENT <br /> Mobiie Food Facility c-aterer <br /> Complete sections 1 and 2. 'f your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT ! <br /> Business NameLh�� C -1L11 Tv d Lic. Plate <br /> Owner/Operator Named( y() <br /> Business Mailing Address���� y(��m \L� W I o cl��Ly2- <br /> City W State(" Zip SZ`{ Bus. Ph�_ 'I 5 1_ Alt. Ph. <br /> 1 F W1� 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, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature_ -- Date z1 I/ <br /> r <br /> 2. To be completed by CO MF Y OWNER/OPERATOR <br /> Commissary Name 2fefe-e, FFA# <br /> Address _ Z�� <�;z� t Bus. Phone (:�09) <br /> City LGIJt Zip_ f'(57— 'SAD Owner,0erator <br /> � P lcW iYcy e <br /> Check all appropriate services provided: ..,� <br /> �stewater disposal M- -compartment sink JB Electrical hook-ups <br /> ,2, j"5�olid waste disposal ood preparation �oilet and handwashing <br /> 2'Hot & Cold water for cleaning i8'Store refrigerated food �otable water <br /> Yd-Istore dry food/supplies b.YUvernight parking Z4e�hicle wash <br /> 14,?_ , hereby state that the information I have provided is current. true and <br /> correct to the best of my 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 notify the EHD immediately. c� <br /> Signature Date l ^ 2 <br /> 3_ To be completed by� �LTHuisd Joaquin Co <br /> The commissary is located in County. The above food fay ':y 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 /> 1:868 E. Haze€m77 �.ve-_= Stockton. California 95205 T 2^9 458-342Z F 209 464-0138 <br />