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`t�-SANANUIN Environmental Health Department <br />SA I —COUNTY— <br />u <br />COMMISSARY AGREEMENT <br />Mobile Food Facility + Caterer <br />Complete sections 1 and 2. If yourcommissery is located outside of San Joaquin County also complete section 3. .. <br />1.1. TO be.00m l6W-b .APPLICANT _ <br />Business Name Lic.Plate# <br />Owner/Operator Name P►le9-0 el� <br />Business Mailing Address 3 A f Z lkNq e l s P(.r-t- L,✓ <br />Clty SI--xKL-af StateC-hZip L-2" L Bus. Ply-2/6%x'99-Cr—z -,OJL Ph. <br />1, /-211 G& --c> , hereby state that the above information is cunent,.trus and correct to <br />the best of my knowledge and agree to utHize 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 FHD. Failure to notify this office may result In permit <br />revocation and penalties. <br />Commissary Name L R Ca ane : C % r„ \ FA# <br />Address a01W E IA"m. U&q y Bus. Phone SCA- • L4614• 1415-20 <br />W <br />Check all appropriate services provided: <br />W 3 -compartment sink <br />Wastewater disposal <br />eWid waste disposal <br />i0 Hot & Cold water for cleaning <br />0 Store dry food/upplies <br />operator fails to comply <br />commissary owner shall <br />O Food preparation <br />© Stow refrigerated food <br />ZOvemight parking <br />0 El�c cal hook-ups <br />W T "let and handwashing <br />�etable water <br />Vehicle wash <br />2 i'l o . hereby state that the information I have provided is current, true and <br />and meets the California Health & Safety Code requirements. If the food facility <br />nditions agreement, or if this agreement is modified or cancelled, the <br />EHD <br />The eommfiUr—yis located in County. The above food facility meets the <br />commissary requirements In Caiifomis 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 />R= -Hs <br />1888 E. Hazelton Avenue I Stoddon, California 95205 l T 209 468-34201 F 209 484-0138 1 www4gov orgland <br />