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SAN JOAQUiN <br /> Date <br />quin Co <br />REHS Signature Date <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 />/A? ? <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Date <br />12k Electrical hook-ups <br />XkToilet and handwashing <br />X Potable water <br />X Vehicle wash <br />hereby state that the information I have provided is current, true and <br />knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />v.'w.v. s_ g ov. c rc e~ c <br />Lie. Plate# <br />Zi Qwner/Operatorf\\fyxA\T) <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i, fi/A-C <br />correct to the besfef knowledge <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notifwjhe EHD immediately. <br />SIgnature Date 0^ [/H <br />Comp/ere secr/ons 7 and 2. !f your commissary is located outside of San Joaquin County also complete section 3. <br />Tofee coveted , <br />Business Name //A, _______________ <br />Owner/Operator Name <br />Business Mailing Address 9^02- Q QV <br />City SfaKWA StateCA Zip %20b Bus Ph J^72?Alt. Ph. <br />. hereby state that the above information is current, true and correct to <br />the best of mylknowledge 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 penalties^—. <br />S ignatu re________ <br />1868 E. Hazeito-Avenue Srockton. California 95205 T 209 468-3420 F 209 464-0138 <br />Com m i ssa ry N ame CO<X\\S\ \ 'ft C CCA__________FA#________________________ <br />Address I ______Bus. Phone ft?Cfo) '22ft-g)33 <br />CityZjjXl Zip O Owner/Operator ) |\\OfVXl ^7 <br />^3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />^.Overnight parking <br />CCy