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JDARIN Environmental Health Deparimen <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility - Caterer <br /> Complete sections ; and 2 is your commissary is located ou�srde of San Joaquin county also comzife'e secr:cn 3 <br /> 1 'To be core feted b.. APPLICANT <br /> Business Name ti K Z Of, Lrc Plate#_ 4 u G w"N <br /> Owner/Operator Name G,tA Le- <br /> y <br /> Business Marling Address i )t N, cti ;Lu <br /> City State Zip�Lgus Ph — I -S'`1 It Ph <br /> hereoy state:nat the Curren'above <br /> true 2n'c correct <br /> the best of MY Knowledge and agree to utilize my apprevea Commissary inrmation is accordance w with,Califorrnia HeafF 1 8 <br /> Safety Ccoe and San .Joaquin County Environmental Health Department (EHD) requirements if t-ie use of the <br /> commissary is discontmuea the permit holder must notrsy the cHD Failure to notify this office may result in aer^ut <br /> revocation and penalties t <br /> 5 gnat ire0, / Date <br /> 2. To be corn ieted by CX)AMMLA'WY_0VMER/0PEMMR <br /> Commissary flame N FA# <br /> Address_�Q� � cm4c O'n _ `L A- Bus Phon�2 Z�-{-233 C-/ <br /> City Zip aSLZ L- Q OwnerlOperator t ` (�•� 'N <br /> Check all appropriate services provided V <br /> t Wastewater disposal s 3-compartment sink Electrical hook-ups <br /> ,47 Solid waste disposal tJ Food preparation VToilet and nanawashirg <br /> Hot& Cold water for cleaning EZ Store refrigerated Food �K Potable water <br /> J Store dry food/supplies � Overnight parking ';�Vehicle wash <br /> t hereby state that the information I have provided Is current true and <br /> correct to the best cr , y knowledge, and meets the California Healt-1 &Safety Code requirements i=t^e food#acr,y <br /> operator fans to ccr-.pty w.tr the conditions of tnrs agreement or f tnis agreement is modified cr ca^cehec Me <br /> commissary owner shall no 7y the EHD immediately <br /> Signature �/f-� Date (,gyp <br /> 3. To be completed by Vw*W,HEALTH junsdiciOn a�of:Sw Joagluin Co. <br /> The commissary s ocated ;n County The above foot ?act:y -.iee.s -,re <br /> commissary •egwrerrents r California Health & Safety Code T ne above checked services are av&able a: ;^e <br /> above carom-ssary Please notify EHD if the status of their operating <br /> permit changes <br /> REHS Srgrature Date <br /> 808 _ raze Ca Tcrn a 9522;, T `3?-3420 F 209 4e4-,.138 _ <br /> P,2fl 5"q F] <br />