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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed b APPLICANT <br /> V <br /> Business Name mkf V1 �P Y l e_ <br /> Owner/Operator Name L i A CrUSC <br /> / <br /> Business Mailing Address___l 1-1 3 OY aYt;U)1f)r i Ve <br /> City 8.10011State('A Zip q� & Home Ph. N/8 Bus. Ph.cRQq-'1 �0 <br /> A l �V3t <br /> I, � i4 ruse- , hereby state that the above information is current,true and correct to <br /> the 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 -N � 4t__ Date S� <br /> 2. To be completed b1,COMMISSARY OWNER/OPERATOR <br /> Commissary Name 6FA# <br /> Address 17-01 1/V. TY)41Y) � Bus. Phonet0qnLya01,LQ <br /> City Zip (v'A Owner/Operator �'4�wc)lcu"W l <br /> Check all appropriate services provided: <br /> Wastewater disposal #3-compartment sink Electrical hook-ups <br /> )� Solid waste disposal ❑ Food preparation ,:Toilet and handwashing <br /> Hot&Cold , er for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Sto ry f d/supplies 13 Overnight parking 13 Vehicle wash <br /> I, hereby state that the information I have provided is current, true and <br /> co ct to the s knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> ope for fa' to comply with t onditions of this agreement, or if this agreement is modified or cancelled, the <br /> com owne alFnoti the HD immediately. <br /> Signature Date \ Y 1GrP Y� 2oZ <br /> 3. To be c0MpD eted b0he 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 />