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SA N JOAQUIN C O U ['4 G C48�iCi��� <br /> i r- .._. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ip, Caterer <br /> Complete sections 7 and 2. If your commissary is IoCsted outside of San Joaquin County also complete section 3. <br /> I. To be com leted b APPLICANT <br /> Business Name Uc. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address 2. 1 <br /> City StateL_Zipg 4 Bus. Ph ``�o� - (}J �j„ Alt. Ph. <br /> 1' ree 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 8, <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�.7 <br /> Signature v��r Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name S iL G"f-FA# <br /> Address �1 V 1 U f.� Sft � � - <br /> Bus. phone <br /> City_ 7 t3,A) ZiP 5 OwnerlOperator �S <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink M Electrical hook-ups <br /> Solid waste disposal Food preparation <br /> Toilet and handwashing <br /> Hot& Cold water for cleaning Store refrigerated food Potable water <br /> i tore dry food/suppli Overnight parking � Vehicle wash <br /> Is ICA, hereby state that the information I have provided is current, true and <br /> correct o the bes�Tm <br /> y knowledge, eets the California Health&Safety Code requirements. If the food facility <br /> operator fails to mply on ' 'ons of this agreement, or it this agreement is modified or cancelled, the <br /> commissary o a immediately. <br /> Signature ) l� b <br /> r� <br /> ' Date lJ <br /> 3. To com let <br /> b 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. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 E 209 464-0138 1 wwvl.sjgov,org/ehd <br />