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SAN J O A Q U I N Environmental Hea th Department <br /> IvI N <br /> COMMISSARY 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 b PPLICANT <br /> Business Name / /" Lic. Plate# ?FO <br /> Owner/Operator Name��., �, CSIyam— <br /> Business Mailing Address hCky, &ze'. <br /> City e, State_CA,.Zip_�s r Bus. Ph.(a0)9W-Z/(0 Alt. Ph.jXa)356 -e7oq <br /> i <br /> I. � A'dyarw , hereby state that the above information is current, true and correct to <br /> thebe'st 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 discon ed t e permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe ti <br /> Signature Date_ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address 1211S. 7�fh S�rY�� Bus. Phone �20q 338-3613 <br /> City /40ole.5�0 Zip 85351 Owner/Operator 611 .S1pr<1u <br /> Check all appropriate services provided: <br /> ,A/ Wastewater disposal -/- 3-compartment sink E,'Electrical hook-ups <br /> Solid waste disposal (Food preparation i✓ Toilet and handwashing <br /> ;:_k/Hot & Cold water for cleaning i,'':Store refrigerated food :Potable water <br /> `!/Store dry food/supplies E? Overnight parking S Vehicle wash <br /> I, B(Ark Luis — GrV'% , 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 to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> Signature 04d 2c Date JG' 2.0 <br /> 3. To be completed by the ENV 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 /> 1 ( ^ ILI H?zelton ,'.venin Stoclklon, California 95205 j T 2Q9 460 '� 2 , <br /> � -�', C i r 209 46•�-0'138 � �n-A^N sligov.org/ehd, <br />