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SAN JOAQUIN <br />Date <br />Date <br />Bus. Phone <br />Owner/Operator <br />4f ortzfo <br />Environmental Health Department <br />r 20S 464-0138 ■ w'mv.s gcv.crg/enci <br />Lie. Plate <br /> 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. <br />CommissaryNam e <br />Address <br />City Zip <br />Check all appropriate services provided: <br />^Wastewater disposal iS^S-compartment sink Electrical hook-ups <br />OK^olid waste disposal (Oj^ood preparation ^"Toilet and handwashing <br />2ZHci & Cold water for cleaning (u/Store refrigerated food EXPotable water <br />i^Store dry food/supplies S^vernight parking □^'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 with the conditions of this agreement or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />Signature ( <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Comp/ete secr/ons 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Namebrand tyetuBMF | <br />Owner/Operator Name ti ■■ <br />Business Mailing Address ^70^ |(v K- <br />CityAjl/v^b StateCA^ipQ^7?^ Bus. PhC^Cy) Alt. Phfecy <br />-----------------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 & <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 fry/faZ/fLp <br />9 To be mmnietprl bv COMMtRRARY <br />FA#_______________________ <br />■868 E. HazeLon Avenue S:ockton. California 95205 i T 209 468-3420