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Pp, C)5L46 <br /> Environmental Health Department <br /> X . Y-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections I and 2- ff your commissary is located outside of San Joaquin County also complete section 3. <br /> ]T-�­16-m-Ax�177-WE <br /> Mar A�113 Re�M- �IPA <br /> Business Nameto Lic. Plate# 9,3- <br /> Owner/Operator Name 5-ftmOt�^% <br /> Business Ph.i hereby slate that the above information is _ <br /> current,true and correct to <br /> the best of my kno v(edge and agree to utilize my approved commissary in <br /> accordance with California Health & <br /> Safety requirements. If the use of the <br /> office may result in permit <br /> commissary is discont Hued, the permit holder must notify the EHD. Failure to notify this <br /> revocation and ties. <br /> SignatureDate_ <br /> J�6 1 <br /> A; N-�IMM <br /> Commissary Name <br /> "2,0 <br /> Acldres� us. Phone <br /> Ly zip <br /> Ci, Owner/Operator <br /> Check all appropriate services provided: <br /> .Wastewater disposal 12"3-compartment sink Cr�Electrical hook-ups <br /> MI-s-olid waste disposal P-tood preparation 2Toilet and handwashing <br /> qHot&Cold water for cleaning (3 Store refrigerated food WPotable water <br /> "KS -,e d. food suppli s 01,16varnight parkingF Vehicle wash <br /> hereby state that the information 1 have provided is current.true and <br /> correct to the best of my nowledge. and meets the California Health&Safety Code requirements. If the food facility <br /> operator falls to comply with the conditions of this agreement, or if this agreement is modified or cancelled. the <br /> commissary oyvcrtall rn thimmediately. <br /> Z!HD <br /> ��' Date <br /> Signal 2? .- <br /> ii j ; <br /> ; <br /> ---------- <br /> IN ITS A ONIN <br /> l'il il�!] PC%- NF— <br /> I A N—1 ;Q 1�:'':,;;1 1"700 <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 cf their operating permit changes. <br /> I <br /> REHS Signature Date <br /> 1868 E.Hazelton Avenue 1 StocK-,.on. California 95205 T 209 468-34201 F 209 464-0138 1 www sigov 01 <br />