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U f T <br /> C 0 M M I S!7-iD A PRY A G R E E M E N T <br /> Mobile Food Facility Caterer <br /> Complete sections Y and 2. lifyoOr commissary is located outside of Son Joaquin County also complete-section 3. <br /> 1- To be completed by APPLICANT <br /> Business Name Lic- Plate 7# <br /> Owner,10perater Name <br /> 9 - 0c,"t Icitcca V <br /> Business Mailing Address— /7/ r- <br /> I <br /> Citystate(Ji Zip qus- Phf�"7,q)�—5n�- lt. ph. <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 /> Safetv Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use or the <br /> commissary is discontinued,the permit holder must nofify the EHD. Failure to notify this office may result in permit <br /> revocation and penaities. <br /> Signature Date <br /> 12- To be completed by COMM ISSAR),"-OWN E--R/OPE RATOP <br /> Commissary Name Pf e6P� wi i!E2A, r Z —FA# <br /> Address 6 Ze,) S s4- Bus. Phone &01) -,2 z-r-; <br /> City zip Z-f !57—y —Owner/Operator <br /> Check all appropriate services provided'. <br /> 'Wastewater disposal -compartment sink iv-- Electric2l hook-LIPS <br /> -V Solid waste disposal Food preparation `Toilet oilet and handwashing <br /> YIq. o'L- & Cold water for r cleaning -.Pllstore refrigerated food ,"Potable water <br /> -F'13—tore dry food/supplies f1-6vernight parking fi'-�, ehicle wash <br /> 1; W4,'h n hereby state that the information I have provided is current, true and <br /> Correct A6 best of my knowledge, and Heats the California Health&Safety Code requirements, Ifithe foodfaciRy <br /> Operator fails to comply with the conditions of this agreement, or ff this agreement is modi-lied or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> Signature Date <br /> r <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 —Zoro <br /> -1868 E. Hazeitosn .Avenue Stockton, Ca4iornia 95205 1 T 20D 4-08-34,20 1 F 20-2 464-OM8 <br />