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i� AN <br /> J Q Environmental Health _De�arTme -_ <br /> COMMISSARY AGREEMENT <br /> Mobile good Facility Caterer <br /> Complete sections 1 and 2. ?f your commissary is located outside of San Joaquin County also complete section 3. <br /> f tjqbe cow e�ted <br /> Business Name Lic. Plate <br /> #_4&(kl�)L� <br /> Owner/Operator Name <br /> Business Mailing Address <br /> city Jtate Zlp _ Bus. Ph.5EA Ph. <br /> i, hereby state that the above information is current, true and correct to <br /> the best of my know#edge 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. Faflure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature pate <br /> 2_ TO be completed by <br /> Commissary Name C Q k ev t e ccj FA# - <br /> Addressuzo �aC2C Gt`(`fJ{1t1� Bus. Phone ZZ -33 <br /> City Zip &q U Owner/Operator Cv7 <br /> Check all appropriate services provided: <br /> Wastewater disposal �A.3-compartment sink �&.Electricaf hook-ups <br /> # Solid waste disposal 0 Food preparation &Toilet and handwashing <br /> Hot & Cold water for cleaning M Store refrigerated ;ood y , Potable water <br /> Store dry foodlsupp#ies ; overnight parking Vehicle wash <br /> 1, C(„ft�CWirti g� - C hereby state that the information I have provided is current, true and <br /> correct to the best of knowledge, and meets the California Health & Safety Code requirements. If the rood 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 noti" 1 e EHD immediately. <br /> Signature Date <br /> in Joaquin Co.� <br /> The commissary is located in County. The above food faciiiy meets the <br /> commissary requirements in Caiifernla 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 /> �aEfTorrlla �JZuCJ f 8-34�'0 F 20G 464-0138 J ':,.,.s y:',. '- <br /> ya�o0 <br />