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4t e E Departmenit <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> CO/77/`)/ete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> //I <br /> Business Ijame <br /> Lic. Plate <br /> Owner/Operator Name 7 <br /> Business Mailing Address <br /> -—Y 7 <br /> C State " Zip ID Bus. P <br /> Alt. Ph. <br /> hereby state that the above information is current,true and correct to <br /> the best of my knov%iledge 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 ang,penalties. <br /> Signature Ali <br /> Date J, <br /> ompleteOty COMMISSARY OWNER/OPERATOR <br /> Commissai), NarneBus. —FA# <br /> Address <br /> Phone <br /> J <br /> City _J__ _1 I" t. Zips Ovttnedoperato <br /> Check all appropriate services provided: <br /> y;=`(Ivastewater disposal <br /> L,/)-pompal-tment sink Electrical hook-ups <br /> waste disposal �dprepar <br /> ation I L,:" l.oilet and handwashing <br /> !,Hot & Cold water for cleaning _,�,"Store refrigerated food Potable water <br /> Store dry food/supplies <br /> C_�_ Overnight parking "Vehicle wash <br /> Q <br /> hereby state that the information I have provided is current, true and <br /> corrEcf to the best of my knovdedge,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,immedittely. <br /> Signature <br /> Date <br /> 3. Tobe completed by the ENV HEALTH iurisdicti <br /> I J171 cl, 'on outside of San Joaquin C-76 <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 /> Date <br />