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Fc_nvi o ental Health Department <br /> -s <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> compiera sections 7 and 2. f'your corrtr ;scar,`- reared outside of San soaquin County also complete section <br /> 3. <br /> let, 13 <br /> LACANT <br /> 0 OP let <br /> Business Name OGk 1ES �X lC>�i� k l'rGlv-��N Lic. �iGew �� <br /> owner/Operator Name <br /> Bus€cess Mailing Address 1"150 �y CYIN Ckf <br /> city StafteCPir Zip-1S9j(P_Bus. Ph. Alt. Ph, <br /> ?Rn_ hereby state that the above information is current,True and correct to <br /> the best of my knowledge and agree 'cc utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmenial Heaith 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 /> -evocation and penalties. n <br /> Signature Date !(� <br /> 1 <br /> Commissary Nam r <br /> 1A lv i I <br /> Address Bus. Phone <br /> City Zip Owner/Operator <br /> Check all appropriate services provided: <br /> wastewater disposal �,V3-compartment sink "Electrical hook-ulps <br /> .Solid waste disposal food preparations Ca"'Toilet and handwashing <br /> t" I t & Cold water for cleaning �e refrigerated food �o able water <br /> uo lies Overn# ht parking Vehicle wash <br /> Store dry roods , p 9 <br /> I hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails t rr;ply with the conditions of this agreement, or if this agreement is modified or cancelied, the <br /> commissary a er !I no" the D immediate#y. <br /> Signature Dare <br /> €he commissary is located in County. The alcove food facility meets the <br /> commissary requirements in California Heaitn & 5afety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> e1 'C <br /> P.EHS Signature ---Date"' R, <br /> 1868 Hazelton Avenue I Stockton. Calific-r-i; r ,:�'2. 7 T <br />