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1 t <br /> Environmental Health ®epartme i <br /> —COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility r Caterer <br /> Complete sections 1 and 2. Ifyourcommissaryis located outside of San Joaquin County also complete section 3 <br /> 1. Tabe.completdd.-by APPLICANT - <br /> BusinessName Mah i'S C&5 r?e:;- C6S 'e511r1d 4 <br /> Owner/Operator Name <br /> Business Mailing Address (/P g O tC2 <br /> City � c /t c�N1 StatK_Q Zip 4s Bus. Ph._& ��Q , Alt, Ph. <br /> 1,1�aFa e1 �voi9 Z q(P Z hereby state that the above information is current,_true and correct to <br /> Ute best 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 discontinued,the permit holder must notify the EHD- Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date �= J <br /> 12.-Tobe tom leted_b :COMMISSARY OWMERIOPERATOR" _ <br /> Commissary Name P r I?; -, FA# <br /> Address IL !Ar'a\ V�ABus_ Phone 146(4 - -/V 5 ?0 <br /> C' � <br /> dY '� U <br /> _ C �U� Zip_ aS 7.0� t]wnerlOperator °`t_'.�n: cn2 <br /> Check all appropriate services provide <br /> Y Wastewater disposal 2"3-compartment sink - /lJf{{ 0 I 'cal hook-ups <br /> e- Solid waste disposal Food preparation W7 T flet and handwashing <br /> Hat&Cold water for Leaning au Store refrigerated food { Placable water <br /> E as Stare dry foo�d/�trpp(ies �vemight parking /�1 , /Vehicle wash <br /> 1•�� �• �/�t_`��f�/77J�"d�Tf hereby state that the information I have provided is current,true and <br /> correct to the best of my kngwledge,and meets the California Health u Safety Code requirements_ If the food facility <br /> operator fails to comply the Iti 'this agreemen, or if this agreement is modified or cancelled, the <br /> commissary owner shall {i e EH imm telt'. <br /> Si ature Date <br /> 3.-Toi)erqgwreted by the ENV HEALTH jurisdiction outside ev sit.Joa tiro ��. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in Calrfomra 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 /> :868 E_ Hazelton,Avenue I &IOdd0n,California 952051 7 209 468-34201 F 209 4BEs-0138 I wm w_sjgov orglehd <br />