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� � � U� 8 � { � ���"���������U ����U�� �����n������ <br /> ���������������� xV� ~~ " ~~~" " " "~"` ~^Department <br /> ~ <br /> ----C()i] NTY---- <br /> G/en/o,ny/��� ��y <br /> COMMISSARY AGREEMENT <br /> �v��o�oxnxx��«�x~xx�� ox~��pv�^�~�~omo�~x� n <br /> Mobile Food FGCilitV ^; caterer ' <br /> Complete sections / and 2 ff your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name <br /> Business Mailing Address'.. ML =Toj 1�f_kc_cr <br /> Cit Y Stu'e',#��/P-�z��z���-""�� r// jd& /`� / //� <br /> | - <br /> hereby state that thoahuveinformation incurrent,true and correct to <br /> the best of r^y knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHn) requirements. |fthe use ufthe <br /> commissary idiscontinued, thu permith |d must notify the EUDFailure tnnotify this office may result inpermit <br /> revocation and penalties. <br /> Signature —Date <br /> 2. 7r0e Completed by-COM N415SARYOWN. M, <br /> Address Ph <br /> Cit — Zip " AS Owner/Operator <br /> Check allappropriate services provided: <br /> M/elkantevvatardispooa| My3'uocopartn1ontoink 131�1electriva| hook-ups <br /> �/ EV' <br /> Food urrnodpreparation U-1-oi|otand handvvashing <br /> ���ut & Cu|dwate|furo|eaAing RJ���«rerefrigerated food C3Potable water <br /> "�'� � _ .^. <br /> M'Sfonadry food/supplies 0'6vernightparkiAg C1Vehicle wash <br /> |, ' hereby state that the information | have provided iacurrent, true and <br /> rorrectto the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails tocomply with the conditions ofthis agreement, urif this agreement iumodified orcancelled, the <br /> commissary h <br /> Signature / Date <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 e <br /> 1808E_ Hazelton Avenue I Stockton, California 952O5i T 2V8450'3420 / F 208464'0130 1nx*w.,jgov»r8/okd <br />