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SAN 10AQUIN Environmental Health Department <br /> COUNTY <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 b APPLICANT <br /> Business Name '�}5 E w �,l Z <br /> Owner/Operator Name Plate# <br /> '� <br /> Business Mailing Address_1-72L. i , J p I tj Cj- <br /> City StateCA zips � Bus. Ph.(101 <br /> -5[21Alt. Ph�2&717 Z/ZIn <br /> I' O , hereby state that the above information is current, true and correct to <br /> the best of my knowledge and ree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin cognty Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, eroffice mit holder must notify the EHD. Failure to notify this may result in permit <br /> revocation and penalties. <br /> Signature /—/r j -- <br /> � Date / �-b`'—� <br /> 2. To be completed b %,UM' MISSARY OWNER/OPERATOR <br /> Commissary Name od <br /> aJ SC1 �ir� LFA# <br /> Address_ <br /> Bus. Phone fit/3 ZS —j <br /> Cit IV Zip___LP} Owner/Operator_ I_TZ2 <br /> Check all app priate services provided: 4 <br /> Wastewater disposal 14 3-compartment sink I# Electrical hook-ups <br /> Solid wastedisposal JP Food preparation <br /> ISI Toilet and handwashing <br /> l� Hot & Cold water for cleaning I Store refrigerated food Jl� Potable water <br /> J4 Store dry food/supplies l Overnight parking T�Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the besf 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 noti the EHD InImediately. <br /> Signature Date 1 j � Z 7 <br /> 3. To be Completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requ' a is in Califor ' Health & Safety Code. The above checked services are available at the <br /> above commissa s if the status of their operating permit changes.. <br /> RENS Signatur Date Fe <br /> I� <br /> CL' <br /> =95205 -,3420 <br /> 1868 E. Hazelton Ave ue I S ckon, Cal1 F 209 464-0138 1 www.sigov.org/ehd <br />