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SAN JOAQUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s Caterer <br /> Cwnp,Wle secimns I aed2. If ya,rr carrxmrssa�y rs hx:aded outs, + ,y Sri,a�'uac}u;n C��u�rdy ansa e.xMf.Jere secl�uro 3. <br /> 1. To be completed by APPLICANT <br /> Business Name�� l ry t� � r.�c� Lic.Plate#, aV <br /> Owned0perator Nam .4e �x.0 r- 2 _ T <br /> Business Mailing Address_ _ <br /> city MCAr_Stab��ip_ Bus. Ph.7r Q_6C5C77m1/ Alt. Ph. <br /> I. 1'1 k� r I n b6''Nr e Z . he rehy stale that the above information is cur rerd,true and correct to <br /> the' of my knowledge and agree to utilize my approved commissary in accordance with CaEfomia Health 8 <br /> Safety Code, and San Joaquin County Environmental Health Department(EHD) requirements. If the use of the <br /> commissary isdisoorttinued, the permit haidermust notifytheEHD. Failure to notify thisofficemay resukinpermit <br /> revocationand penalties. <br /> Signature n 1\cc 'r 10 t'_l I Z Date n -�- 2e) Z-c,Z <br /> ' 2.To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name FA# <br /> Address�1� Al _Bus. Phone�M��Ltl 1�� <br /> City_ nk'S Zip wnern'Operator�f l-4 , Y'm <br /> Check all ap <br /> pro pdate sera ices sprovided//: <br /> Wastewater disposal eri -compa r tme nt s in k D'Eleetrical hook-ups <br /> Ef Solid waste disposal d Food preparation ZY'Toiilat and handwashing <br /> d Hot &Cold water for cleaning dStore refrigerated food Potable water <br /> LI/Store dry fgRdlsurp'pljen ,EfOvernight parking ZfVehicle wash <br /> yl\I`�.I hereby state that the information I have provided is current,true and <br /> oorrectta the bestaf myknowiedge,and meats the Caliorrua Health 8 Safety Code requirements.. If the food faclty <br /> operator tails to comply with the conditions of this agreement or f this agreement is modified or cancelled, the <br /> Date <br /> commissary r shelf natty th EHD immediately. <br /> igna <br /> Sture �r�< s+ <br /> 3. To be completed by the ENV HEALTH Jurisdiction outside of San Joaquin Co. <br /> The commissary is krcated m ."l ',r/. (' �wsArty. The above food laciity meats the <br /> commissary requirements in Caliu <br /> amia Health E Safety Cade. Ti-.0 he ove checked services are available A the <br /> above commissary. Please notify EHD it the status of their operaling permitchanges. <br /> f2EHS Signature Date J 11264 2 <br /> 1808 E. HazetonAvenuel Stockbn,Catitarria95245I T 209 468-3420 1 F 209464-0138 lwww.s;gov.orgrehd <br />