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SAN JOAQUIN <br />c <br />Date <br />Date <br />'c. e-c <br />•^tiectrical hook-ups <br />^4>roi!et and handwashing <br />QZPo^aie water <br />Vehicle wash <br />Environmental Health Department <br />ww.v. s gov. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 7 end 2. If your commissery <br />T To be completed bv APPI IO Ah <br />IS located outside of San Joaquin County also complete section 3. <br />IT * ~~ ------------ ------ <br />Business Name^! _ lq <br />Owner/Operator Name <br />Business Mailing Address S /jf} / <br />------State^Zip,,^^^ Ph Z^L^M^lAlt. Ph <br />thp hpe^nT a--------Z------------------- hereby ST2Te tnai The above information is current, true and correct m <br />Sate-v Code -nd Z 86 my appr°Ved emissary in accordance with California & <br />a ety Cooe and SGn Joaquin County Environmental Health Department (EHD) requirements me v ^h- <br />T ™ :’s — ~ •»»w iS “• <br />iz/ig /20Z.5 <br /> f <br />—t— --Jietea ^H^iNy HEALTH jurisdiction outs<te_of San Joaquin Co <br />s" j js “ Si E:h"~'2»™ 2 <br />REHS Signature, <br />Lie. Plate# 3^Sy503_ <br />Commissary Name z^-~ /) FA# <br />Address^? Zrf—H________Bus. Phone Z ZY- <br />C>ty------- --------------------------zip"j -J Owner/Operator / <br />Check all appropriate services provided: <br />Q^GVastewater disposal ^^compartment sink <br />^mSoljd waste disposal /^P^ood preparation <br />^Ao?^ Cold water tor cleaning ^^tore refrigerated food <br />2L<xore dry tood/supplies ^Overnight parking <br /> coment1------FC--------3--------hereby state that the information I have provided is current, true and <br />correct Lo^the best of my knowledge, and meets the California Health & Safety Code requirements If the food facHty <br />operator iails to comply wnh me conditions of this agreement, or if this agreement is modified or canceiled the <br />commissary owner shall notify the EHD immediately. cancenes. me <br />Sign ature <br />'868 E. Hazei-cn Avenue StocKton. California 95205 T 209 468-3420 F 209 464-0138