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��".AN JOAQUiNi <br /> ---.---COU i\I i ti--- <br /> COMMLSSARY AGREEMENT <br /> Mebiie Food Faeiii'hj Caterer <br /> Coinplete sections I and 2. 1fSrour corrin�issar}t is located outside of San Joaquin County also complete section 3. <br /> completed by APPLIOANT <br /> Business Nameenn , Lic. Plate## <br /> Owner/Operator Name z <br /> Business Mai ing Address -3 <br /> Cif<r > Stafej�4 Zip ��S�Bus. Ph. V;jj- QL,' Alf. <br /> I,` et is hereby state that the above infoanation is current,true and correct to <br /> the best of nay knoviledge and agree to utilize my approved cormmissai-y in accordance vLlith Califomia Health Z: <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 /> Signature Date <br /> F2-.–T0 be completed by COMMISSARY OWNEWOPERATOR <br /> Commissary Nara PA# <br /> Address ` E-- � l'G Bus. Phone <br /> cityr ., Zip 0vLin-r1Opera'ior ( � /Vp <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-co.11parimenf sins; X Electrical hook-ups <br /> solid waste disposal Food preparation � Toilet and handwashinc� <br /> W Hot& Cold water for cleaning Store refrigerated food Potable water <br /> ore ry food plies Overnight parking `i Vehicle wash <br /> G <br /> hereby state that the information 1 have provided is current,true and <br /> correct to the best of my knowledge, nd meets the California Health&Safety Code requirements. If the food facility <br /> operato'ails cornPly vAth the nditrons of this agreement, or if this agreement is innodifed or cancelled, the <br /> commissaij my ne}shall notify t HD irrinieciately. <br /> Signature ; �` Date <br /> & To be corn Meted by ti iia ',---N� i EALTH jurisdiction outside CIV Sale JOiq—w� (50- <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health 9: 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 /> RENS Signature Date <br /> '180.6 E. i-iazelton Averme 6 Stockton, California 95205 ``° 209 463-3420 1 = 202.461-013L <br />