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SAN J 0 A UIN: Environmental Health Department <br /> COUNT — n <br /> k 1! <br /> r: <br /> GY?P.%G CSS GYGWi �L".'f., - , <br /> COMMISSARY AGREEMENT ; <br /> Mobile Food Facility 4, Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin Countyalso complete section 3. <br /> Business Name Lic. Plate# <br /> ��1 �� <br /> Owner/Operator Name_�`��. i�1 `�/Y1�ZP S a �: <br /> Business Mailing Address ZZ�j � J aCk--Sco U rV� Ott' <br /> City�'4 \�p✓���J�41 State Zip-1, (9-1 Bus. Ph.?- ��� ZCG tZc Alt. Ph. <br /> I, i V It r�IXJhereby 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 & <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 anq penalties. <br /> Signature Date 2k <br /> i <br /> 2'tTo'tti`e'„com feted=b CO.MMIS,S"ARY OVII�IE[�Z/Q`PERATbR x <br /> Commissary Name Za ! I7mjje-ria 4ojes4-o FA# <br /> Address U l t .5- -9�4'` ,54rep/- Bus. Phone 6j09) 338- 3.66 3 <br /> City AodZd-o Zip 95351 Owner/Operator rnl Sfonaae l�µ�%ss�v.ln�• <br /> v <br /> Check all appropriate services provided: <br /> 13 Wastewater disposal 91 3-compartment sink El Electrical hook-ups <br /> Solid waste disposal Food preparation ® Toilet and handwashing <br /> Hot & Cold water for cleaning 13 Store refrigerated food ® Potable water <br /> Fad' Store dry food/supplies 0 Overnight parking 13 Vehicle wash <br /> lUaf!/ (tel-S- CNS 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 /> Signature' Date <br /> 3�Toube„com slete'dFbunth ENUYNEA �TH1 unsdlct on,touts de of San Joa. u n Co-': <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in Califo nia Health & Safety Code. We above checked services are available at the,,' <br /> atiove commissary. Please notify EHD if the status of their operating permit changers. <br /> REHS Signaturvenue <br /> Date f <br /> 0 <br /> 1868 E. Hazeltockton, C is 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd ? <br />