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SAN )0 A Q U I N 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 a <br /> 1 . To be completed by APPLICANT <br /> w , . Di T,3 <br /> Business Name SNS ` i Plate# r <br /> Owner/Operator Name r;i&, 3 tE� AA jloc 2-AiiPjLjt—LA <br /> Business Mailing Address ,; 1 akfLl !Q l ti CT- <br /> City a State(A Zip` � Bus. Phi7ol Alt. Ph#07)7�k­ Zll( <br /> I, O 'at iTgC IQ 2"i , 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 C?,4nty Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,,! ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> fdzz <br /> Signature — <br /> �3 <br /> Date1_ <br /> 2. To be completed �b,, COMMISSARY OWNER/OPERATOR <br /> �p <br /> Commissary Name I(" `t ft od f I ( �A N FA# :�F <br /> Address &W L> f/ L Bus. Phone .� <br /> CityiQ ZipPf Owner/Operator <br /> Check all appip_nate services provided: ,fir <br /> 1A Wastewater disposal 3-compartment sink rqr Electrical hook-ups <br /> M Solid wasteldisposal Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaning Store refrigerated food Potable water <br /> ¢� Store dry food/suppliesJ1 �Q Overnight parking I Vehicle wash <br /> ��n � <br /> I, L SEN , hereby state that the information I have provided is current, true and <br /> correct to the besi 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 nob the EHD i ediately. <br /> Signature Date ( � Z <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in tq'fAV NA!T' 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. n,�y� <br /> REHS Signatur r Date F 4 !41 <br /> IJ Ntn(7 QM) fEF71 <br /> 1868 E. Hazelton Ave ue I S ckton, Cali rnia 95205 3420 F 209 464-0138 www.sjgov.org/ehd <br />