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�? 10AWN Environmental Heaath ®epartme <br /> C OU N <br /> COMMISSARY AGREEMENT <br /> Mobile Food ;°acid'ay Catea ai, <br /> complete sectfans f and a if yourcommissary is located outside of San Joaquin Couniy also compiei-e seaffon <br /> I. 7a. be.'mi pdeted.-b . APPLICANT �r <br /> Business Flame t--0 �G1�n 1-n U i-ic-Plate# <br /> Owner/Operator Name o cx ro -cas QY+r u l a 5 <br /> Business Mailing Address 2S S K�,\ cis l eq Ave_ <br /> Olt�� S�cxk-� a €ic—LL Q5.Lo3 Bus. P:,. Ali. Ph. <br /> 1,Amp cirD Cc{S G r+/U toICc S hereby state that the above information is curmn4jrue and correct to <br /> Use hest of my Knowledge and agrea to ut lize rnir approved commissary in accordance with California 'fealth � <br /> Safety Code, and San Joaquin County Environmental Heaith Department(EHD) requirements. if the use of the <br /> commissary is discontinued;die permit holder must notifi the EHD_ Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature ��nC� 0-Cc 5C1V' V'J h i �S Date — Q 9 ^ 202n <br /> 21o� bra CO1 P16ted.by CCiNIMISSA tz Ul.AINERIOPE c T O <br /> .f".animissary Nar 8 FA# <br /> r <br /> Address ��Qjrk. 4 &2- , Bus. Phone <br /> ' . <br /> city �c);� .ir Ufa l� ?yO�a t3wnerlOperatoa� <br /> Oheck all appropriate services provided: <br /> r ' Wasiewaier disposal --compartment sink 2,181 -cal hook-ups <br /> 80110 waste disposal f=ood preparation, V' and handwashing <br /> s" <br /> €poi Cold wafer far Cleaning ZZ, More sefi7gc;ated food i a hle water <br /> Store dry fofPdlsupolies a^ Oxerrtigh►{writing Y 'tilehicle wash <br /> •• �/ �iV '� i 4 / <br /> �f,�lZ— .hereby M2 that the infornatian i have provided is currant,true and <br /> correct to the Fest of my I owledge,and meets the California Health&Safebj Code requirements. if the food facility - <br /> operator fails to s:,arnply -die conditions of Vnis agreement, or if this agreement is modified or cancelled, :lie <br /> commissary ovrrier shall the a- 1D to er1iately- <br /> ignaiure Date <br /> 4 � <br /> cora,,Od by�-he ENV HEALTH Lwiadieio �3Ltaide c San �oagUin 0 <br /> i he commissary is located in County. The above rood facility meets the <br /> commissary requirements in Caiifomia 1,2alth & Safetij Code- the above checked services are available ai fne <br /> above comrnissanj. Please notnj EHD i,;he status of their operating permit changes. <br /> REI-1S Signature- Date <br /> .a~eitoz/=vsnce j Szac,.carr: 321rornia 255/1-05; ;tl@ 4eS349_01 }' 202 4-64-0138 1 vRmsjga�.r_orcicl?�: <br />