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SAK40AOUIN Environmental Health Department <br /> N,' <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility e Caterer <br /> Complete sections ` and 2- lr your commissav is located outside of San Joaquin County also complete section 3. <br /> Business Name LAS S OLic. Plate# b -, <br /> Owner/Operator Name Z <br /> Business Mng Address <br /> City a' iState Zipus. Ph It. Ph. <br /> I. w ,hereby state that the above information is current,true and correct to <br /> the best of my mowledge 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, permit holder must notify the EHD. Failure to notify this office ma result in permit <br /> revocation and es. <br /> Signature Date (/ <br /> t��Cy77' <br /> Ahla <br /> nY Commissary Name Ado' s us. Phone � <br /> City C Zip Owner/Operator <br /> Check all appropriate services provided: <br /> ewastewater disposal j3--3-compartment sink i3'Electricai hook-ups <br /> olid waste disposal mood preparation tX�Toilet and handwashing <br /> 0 riot & Cold water for cleaning 12 Store refrigerated food I 'Potable water <br /> CkS a dry food/supplies X116vernighi parking �ehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge;and meets the California Healtr,&Safety Code requirements. If the food facility <br /> operator fails t mply with the conditions of this agreement, or if this agreement is modifi or cancelled, the <br /> commissary o er II no ' +he D immediateiy. <br /> Signature Date / <br /> } <br /> The commissary is locatec 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 rj e l o ei C <br /> SRS8 E Ha7altnn Avonr,o i Rt,,vtnn (`3ii?n.r i-.oaonc v+.v n-..A . <br />