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Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3 <br />Lie. Plate# <br />£0 <br />Date. <br />FA# <br />Date. <br />REHS Signature..Date. <br />HaT-JTr. A.rrjc: St x k*o >. Cclifcn> SS’C'i! T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />P 3-compartment sink <br />K^food preparation <br />Store refrigerated food <br />S-Overnight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SANJOAQUIN <br />COUNTY <br />4a <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name \ev«l$rp p <br />Address <br />CityXV\a-V\j~<C4— Zip <br />Check all appropriate services provided: <br />□^Wastewater disposal <br />ED Solid waste disposal <br />/^Hot & Cold water for cleaning <br />13- Store dry food/supplies <br />____ <br />________Bus. Phone <br />Owner/Operator. <br />[^Electrical hook-ups <br />EL.Toilet and handwashing <br />Potable water <br /> Vehicle wash <br />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 with4be conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall nodtyJie EHD Immediately. , <br /> Signature ---------- ------------------------------------Date <br /> <br />13. 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. Please notify EHD if the status of their operating permit changes. <br />11, To be completed by APPLICANT_____ <br />Business Name,VAeS Co. <br />Owner/OperatorName <br />Business Mailing Address IMXkn <br />City Statef*^ Zip'QS^Ma Bus. Ph.Alt. Ph.~7(fl <br />___, hereby state that the above information is currenL 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 penaltri <br />Signature_______