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—COUNTY-- <br />COMMOSSARY AGREEMENT <br />Mobile Food Facility � Caterer <br />Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />11 a Te: bqompleted = y APPLICANT <br />Business Name Zei7 s.tL A, Lic.Plate#00✓--.2, <br />Owner/Operator NanSe &4 l &7� f� - <br />Business Mailing Address _�eY5{� fG wwr�/irk <br />City. 3+va-� D�- State� 4 Zip "5JtA7 Bus. Ph.,2d9'SyN (oltllAlt. Ph.,)yL x{33 -- `t'61,1 <br />I, , 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 a <br />Safety Code, and San Joaquin County Environmental Health Department (END) 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 Date 6� 2- <br />2; 9eted b . COMMIISSAIR 'OWNER/OliEtATOF? <br />Commissary Name L A 6 A'Z mec c"i & \ FA# <br />Check all appropriate services provided:: <br />Wastewater disposal 3 -compartment sink <br />e /olid waste disposal <br />lr Hof & Cold water for cleaning <br />i`1 Food preparation <br />0 Store refrigerated food <br />tical hook-ups <br />T 'let and handwashing <br />r P 4able water <br />Ire ,Store dry food/supplies ZE_11110vernight parking Vehicle wash <br />l OaV t fZ11li�� �— , hereby state that the information I have provided is current, true and <br />Correct to the best of my knowledge, a d meets the California Health S Safety Code requirements. If the food facility <br />operator fails oin with the c eons of this agreement, or ff this agreement is modified or cancelled, the <br />commissa ower shall notify th ND immediatet <br />Cinnn4nro � :'vl ..,-c. t /%�ftil_.'i.9Gf ��i/� <br />The commissary is located in <br />commissary requirements in California <br />above commissary. Please notify Etp, <br />REHS <br />County. The above food facility meets the <br />Ih & Safety Code. The above checked services are available at the <br />status of their operating permit changes_ <br />296® E. Hazahon Avenue I Stoctdan, California 952051 o 209 469-34201 F 209 464.0139 I www.$)gev.org/ehd <br />