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� � &U �� Q � � � <br /> } � � �� ��� X� 0 � Environmental Health Department <br /> --C ]UMTY-- <br /> _ <br /> COMMISSARY AGREEMENT <br /> Mobile Food F8Cilhn � Caterer ' <br /> ' <br /> Complete sections Yand 2If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed by APPLICANT <br /> ' <br /> Owner/Operator Name <br /> qq <br /> Business Mailing Address <br /> I, TU6( MRKkUL, 85&C-GO 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 (EHO) requirements. |fthe use ofthe <br /> commissary the,permit holder must not the EHDFailure to notifythis office result in it <br /> Signature Date <br /> completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UN MCIAP <br /> mJ CA —Owner/Operator <br /> Check all appropriate services provided: <br /> Ivf�m"stewaterdiapoaa| ���-oocnpartmentoink eElectricalhook-upo <br /> - ���� <br /> a��So|idvvaatadisposal EY"Food Toi|etand handvvaahing <br /> ~� <br /> m .�z <br /> ws not & Cold vvaterfor cleaning �� Store refrigerated food ..° otab|e water <br /> OT"Store dry food/supplies °�/�ve[Oightparkjng Y/</ehio|ewash <br /> |. . hereby state that the information | have provided iucurrent,true and <br /> oomanttothe best ofmyknowledge, and meets the California Hao|th &SofetyCoderequinemento. |fthe food facility <br /> operator fails to comply with the conditions of this ogreemant, or if this agreement is modified or canoe||ed, the <br /> commistheE immediately. <br /> Signatureat � <br /> 13. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin C:o�] <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements /n California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHOifthe status oftheir operating permit changes. <br /> REHG Signature <br />