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l <br /> i�c <br /> t <br /> SAN f 0 A Q U I, Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 1 and 2. if Imur commissary is located outside of San Joaquin County also complete section 3. <br /> 1 To be completed APPLICANT S <br /> {� t 4 1 Lt1 i �`:l L ''I i (� i J rr. L J <br /> Business Name t ( 4r 1.. 11� I ___ f � -� 17(i c. Pi #"t,, l _3yc a <br /> Ownerioperator Name <br /> Business Mailing Add ess s�}�(t ��l � ''•' �� i`� <br /> CI1 <br /> City "7 { State Zipt.;l/.J4' 1-_'1 r ° Bus. W)iu -At ..c.�it` P,It. Ph.`�M;' ` �1 .d ;Ll <br /> : 1 <br /> 1, C• I"-f- CA i 141 j e C .hereby stale 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 (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 ano n`altigs. <br /> pe <br /> Signature �kh A! OU LI Date <br /> 2.To be completed by COMMISSARY OWNER/OPERATOR r� <br /> Commissary Name I �t FA# 'PA- <br /> Address 1�- --��A� fjt/ - Bus. Phone //I�LE W- 7-7170 <br /> CAY •�1P.NVtrtDy� Zip YSS� Owner/Operator liit�YLi�W - <br /> C/heCk all appropriate services provided: <br /> �t4'astewater disposal 12 3-compartment sink ,/ <br /> / 1': Electrical hook-ups <br /> L Solid waste disposal =;, Food preparation ' <br /> %poiletab and handwashing <br /> 1� Hot&Cold water for Leaning €;,;i Store refrigerated food <br /> M Store•-,,o supplies P table water <br /> l/1iltlf✓' Wpl eS Overnight parking <br /> 1. I Vehicle wash <br /> carrect is the best of m .hereby state that the information I have Provided is current,true and <br /> oparator fails fo co y knoveledge,and meets the Calitomia I-lealth&Safety Code requirements. If the food facility <br /> commissary ovr mPly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> e�I shall notify the EHD immediately, <br /> Signature �� <br /> --- Date <br /> The 7D COQ e of San <br /> feted b the ENV HEALTH Wrisdiction Outside Joa uin Co. <br /> cn <br /> o tarsus--I is located in <br /> aarssary requirements in Carlo <br /> above COMM,wsa mta Healt &Safe County- The above food facility ry' a rno[ify E O if the status of heir operThe above checked services are avail at the <br /> REr1Sgrwture 9 Permit ch a a. <br /> Date l <br /> tab&E.Hazelton Avenue I Stockton. <br /> Ce"fomia 952051 T 209 466-3420 1 F 209 464-01 8 <br /> sj v.orgfehd <br />