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J {jQ N Environmental Health Department <br />•' ' , '� —COUNTY— <br />i <br />��troaP.c7 Greotness grows here. <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 by APPLICANT <br />Business Name C-1 -_Tn f n `k to M;wUerl-a Lic. Plate# `i SS LI I RSI <br />Owner/Operator Name SoSa C C-,e-�mPZ <br />Business Mailing <br />city Uo,cL +n State_PAZip 535 Bus. Ph. ( ?�09 5 'tk 11 -Alt. Ph.(% O' -i ) S RI ± 16 0 <br />hereby state that the above information is current, true and correct to <br />thLs'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 andpenalties. <br />Z .4 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName 44 60"isarsn M Odds+° FA# <br />Address );Lit S. �SI �¢e } Bus. Phone (200391-3&63 <br />City /yod4540 Zip 45351 Owner/Operator Cold 54er43c Conn'Isay, lnc. <br />Check all appropriate services provided: <br />Wastewater disposal Er3-compartment sink VrElectriCal hook-ups <br />Solid waste disposal 12Food preparation M I octet and handwashing <br />' M'Hot & Cold water for cleaning MStore refrigerated food 0- Potable water <br />E(Store dry food/supplies De -overnight parking C -vehicle wash <br />I, 4o,k Geis -CeVt , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in <br />commissary requirements in ( <br />above commissoryr. -Pre4e nc <br />REHS <br />lS -1lZ County. The above food facility meets the <br />Health & Safety Code. The above checked services are available at the <br />operating permit changes. <br />1868 E. Hazelton Avi?nue 1466Mottl, CaliforA(t 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />