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A Nj O AQ U Environmental Health oepartment <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Racili°y* Caterer <br /> Complete sections 1 and 2. It your commissary is located outside of San Joaquin County also complete section 3. <br /> im feted by APPLICANT <br /> Business Name Lic.Plate# <br /> Oigner/Operaior Name /uP Sf�) L)/o ` / <br /> Business Mailing Address 5-/C?0 W. Zt 1_JU 9`7 # 2-q`- <br /> CH J C-44- State 6 A Zip S�Bus. Ph.,O q- q C/n `Ib 5 Alt. Ph. <br /> I�.�U e5 tZlyt n <f&jZ g , hereby state that the above information is current,true and correct to <br /> the bestof 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 l(�' �5 y�-- <br /> 122'. To be completed:by COMMISSARY OWNER/OPERATOR � <br /> co6''V'2misSc` vy Name LA 1 Co` xe a l_%CA 1 FA# <br /> Address -AL rxd- za waN Bus. Phone �{�(• �'� (7 415 �d <br /> City 0 5yr�4_ko - zip 1,J 2:0-6 operu'I�cr CA(.:{n <br /> Check all appropriate services provid <br /> e <br /> d <br /> : <br /> UWastewater disposal ?3-cormlpariment sink Et 'cat hook-ups r <br /> Food preparation <br /> T 'let and handwashing <br /> e olid waste disposal 13 p p <br /> jr <br /> ot&Cold water for cleaning © Store refrigerated food ble wa.er <br /> Ovemi ht parking "Vehicle wash <br /> � S dry food/supplies 9 P 9 <br /> I, iY✓U/E �� K/Il, � 7- ,hereby state that the information 1 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 *shall notify the E m <br /> mectiately. <br /> Signature Date <br /> 3. Tobe completed b j` a ENV HEALTH "uhisdictici or tzid ..n ,9oe c is Co. <br /> The commissary is located inCounty. 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 Data <br /> 1868 E.Hazelton:AxseiLur.j Sioci;ton,California 95205 • �;. 34.20 i �� ��iw'�`` u c�_r «ti�r.sigat_c<< fct <br />