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11 <br />imarroar <br />SAN JOAQUIN <br />-- COUNTY •-- <br />.EnvImawirer.,a1.119TAIth <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ei Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Pk <br />80c (5-)LIE(1 \ifunb.u-F-L ifo13ptie.,06 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 scentinued, the pe,çmit holder must notify the EHD. Failure to notify this office may result in permit revocation an pen es. <br /> Data ?) <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address 11 11 S U OW ST Bus. Phone 1-01 124-s/if (0 <br />city(51)( e3152()O Owner/Operator P--1),C1 FEN Ti P-ADO <br />Check all appropriate services provided: \ I VtitN 1 " <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />, hereby state that the information I have provided is current, true and <br />,and meets the California Health & Safety Code requirements. If the food facility <br />onditions of this agreement, or if this agreement is modified or cancelled, the <br />Signature <br />HD immediately. <br />Date 'Li Z-40 76 1,5 <br />To be completed by the ENV HEALTH 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. Plsase notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />1858 E. Hazelton Avenue! Stockton, California 95205 I I 209 468-34201 F 209 464-0'138 1 www.sjgov.orgiehd <br />Ro5scrio2... <br />Business Name DoSf42 011-1 LIU Lic. plate# sce 99 Li (.0 <br />Owner/Operator Name <br />Business Mailing Address <br />City 511)(RM kIState CNZip15 2.-01Bus. P Ph <br />Signatu <br />SS-#4 <br /> <br />UC FINITK <br />\I I <br />_ Storeel,f, fogid/uptes <br />I, <br />s,A <br />correct to the best of my know <br />operator fails to corn <br />commissary owner <br />3-compartr&nt sink <br />X_ Food preparation <br />Store refrigerated food <br />Overnight parking <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash