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"' AN JOAUHN <br /> Environmental health De f-mrtaient <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT j <br /> Business Name ao � 44-t_ Lic. Plate <br /> Owner/Operator Name <br /> Business Mailing Address /30 <br /> City State&4 <br /> Zip Bus. PhaDq-a1S'- &q1/ ' Alt. Ph.o34f IT-$-6 3'k <br /> 1,4,9q ('aNrruIIL9 144C®o `OT4q 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 ho er must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe It, . <br /> Signature -.--w____._.-. Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FAi= <br /> Address ell <br /> n&irBus. PhoQne d,p //- <br /> City 1 J%�y- Zip g5ao Owner/Operator <br /> Check all appropriate services provided: <br /> 21 Wastewater disposal N 3-compartment sink ! Electrical hook-ups <br /> g( Solid waste disposal L3 Food preparation Toilet and handwashing <br /> IN Hot & Cold water for cleaning U Store refrigerated food El Potable water <br /> Q Store dry food/ upplies r, 16 Overnight parking vehicle wash <br /> I, hereby state that the information I 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 /> operator fails to comply with the editions of this agreement, or if this agreement is modified or cancelled, the <br /> commissar o✓ner shall noti EHD imme tely. <br /> Signature Date <br /> 3. 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 /> REHS Signature Date <br /> lvcd 'E. ice_ ion A'v ilUe I Stockton. aliiOrnla S15205 I T —709 468-3,120 1 F �) n <br /> � 4�4-G 13_ .sjg vary' .�d <br />