BOX 129261, SAN DIEGO, CA 92112-9261-2025

1. Click ‘Get Form’ to open it in the editor.
2. In Section I, enter the Facility Name, Health Permit Number, and Facility Mailing Address. Ensure all details are accurate for proper identification.
3. Complete the City, Street Number, and Zip Code fields. This information is crucial for regulatory compliance.
4. Provide the Permit Owner Name and contact details including Fax and Phone numbers. This allows for easy communication regarding your application.
5. In Section II, the Commissary/Headquarters Owner must authorize the food facility's use of their premises by filling in their business details and checking applicable permissions.
6. Ensure that both parties sign and date the form at the bottom to validate the agreement.

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