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i <br /> � 'if�f ,I (�I�QI_) � f� 11 V;r01-t�a'1��r�i<�3 <br /> COMMISSARY AGREEMENT , <br /> Mobile Food Facility Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be com feted b PPLICANT <br /> Business Name Atc, Lic. Plate# 7EI-) R <br /> Owner/Operator Name // __ C <br /> Business Mailing Address 39.2 �C�'dJ%1h ,'Z AiP <br /> City J. e _State_CA, Zipq0&jBus. Ph.(,-LQR),*W-Z—V(o Alt. Ph.(V4)35&x'70q <br /> I,•��q�,21V,2 t hereby state that the above information is current, true and correct to <br /> the b t 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 diRu� <br /> permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p <br /> Signature Date �JD <br /> 2. To be com feted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La FA# <br /> Address 4211 J!. fk .SrtnL • Bus. Phone - 335-3663 <br /> City_ 1,40AAo Zip 85351 Owner/Operator 61,1.%T <br /> Check all appropriate services provided: <br /> A/Wastewater disposal �3-compartment sink Electrical hook-ups <br /> ✓Solid waste disposal /Food preparation ✓Toilet and handwashing <br /> ./Hot& Cold water for cleaning ✓Store refrigerated food :Potable water <br /> ✓Store dry food/supplies /Overnight parking Vehicle wash <br /> I, mark Iu;s - 6 r1 , 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 -Date Jr�"�o <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 Signaturey� Date 5!7/T07 <br />