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SAN JOAOUIN Environmental Health Department <br /> ;A: COUNTY— <br /> - <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility* Caterer <br /> Complete sections land 2. if your commissary is located outside of San Joaquin County also complete section 3. ... <br /> 9.To be som letdd by APPLICANT <br /> Business Name L JOS Uc.Plate# 3 U L55s"' <br /> Owner/Operator Name a5 a `a . <br /> Business Mailing Address' Y D S 1q,»e cV S <br /> CityLC1eState Zip LBus. Ph'�a-VIII�3 Aft Ph 9 54LL--A. j <br /> hereby state that the above information is current,_true and correct to <br /> the best of my knowledge and agree to utfi'¢e 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 Jr9S P F yc lr CL _Pate_q-422 ( 6Z <br /> 2.To be completed 4Y COMMISSARY OWNERIOPERATOR <br /> Commissary Name L A C(ripec C.%&k FA# <br /> Address n.qM E ryAAAe v`t Bus. Phone oM• AAL1 6 0 - �l S �70 <br /> City �JkU�{Gkc�n Zip a(SZoS Owner/Operator C,n:() 1-� Cr'1P.kk <br /> Cheek all appropriate services provided: <br /> WVastewater disposal 3-compartment sink cal hook-ups <br /> e/olid waste disposal Food preparation /T�r'let and handwashing <br /> O Hot&Cold water for cleaning FM Store refrigerated food 1174 P bie water <br /> 0 Store dry fo d/sup ii s VYOvem19ht parking Vehicle wash <br /> i, (, • r • io R!%r tf 2 .hereby state that the information i have provided is current,true and <br /> Correct to the best of my owledge,and meets the California Health&Safely Code requiremerds. If the food facility <br /> operator fails to <br /> comply th �nditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall the EHDidiately. ­' <br /> �^r /1 t1 <br /> ignaturs _� j Date. "1 Z aO9,0 <br /> LLq be.wgRreted 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 /> 1868 E Hazelton Avenue[ Sioctdon,California 952051 'r 209 468.34201 F 209 464-0138 1 www.sjgov org/ehd <br />