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a l ��i �lq���� <br /> .fit Jw ' '�.[ <br /> ---COUNTY— <br /> CcO�r�WSSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete,sections 1 and 2. If your commissary is located outside of San Joaquin"County also complete section 3. <br /> 1. To be completed bAPPLICANT <br /> Business Name Lic. Plate# <br /> Owner/Operator Name e f" <br /> Business Mailing Address 3.b V) ill mman LFvvP, YSL <br /> City 'S�z<_L-or. State aZip Zl Bus. Ph. Alt. Ph. <br /> I, ��r'r- Cwsc ea _ —, hereby state that the above information is current,true and correct to <br /> the best o my knowledge 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 and (ties. / <br /> Signature �'/ Date 1-7 !2c7 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 7 FAO <br /> Address S S -� Bus. Phone — f <br /> City /r�> Zip --- �7_ Owner/Operator <br /> Check all appropriate services provided: <br /> �.V Wastewater disposal C 3-compartment sink Electrical hook-ups <br /> _V Solid waste disposal R Food preparation 'Toilet and handwashing <br /> Hot& Cold water for cleaningStore refrigerated food Potable water <br /> C Stored food/ upplies : Overnight parking Vehicle wash <br /> I, P Mme_ hereby state that the information I have provided is current,true and <br /> correct to the best of my kno ge, and meets the California Health&Safety Code requirements. If the food,facility <br /> operator fails to comply witfrthe conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall theHD i ' tely. <br /> Signature Date <br /> 3. To be completed by the W 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 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 7 209 468-3420 1 IF 209 464-0138 1 www.sjgov.org/ehd <br /> V"-7 9 o <br />