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SAN_.*JOAQUIN Environmental Health Department <br /> COUNTY— <br /> _. �-:ar•.:ru» - .:_ _ :-� - -- <br /> COMMISSARY AGREEMENT. <br /> Mobile Food Facility* Caterer <br /> Complete sections 1 and 2. ff yourcommissary is located outside of San Joaquin County also complete section 3. <br /> Business Name �d_ Lie.Plate# /7'V6 7d Zr,, 6 <br /> Owner/Operator Name ` <br /> Business/,Mailing Address e"✓ <br /> cily_�7�-7C(�l� st2teC� zp9.S`a/y sus. Pr,�a9-3/1�"�i97y lit Ph,��'� 3d/-oa7y <br /> I, hereby state ihat the above information is currentjrue and coned to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health e <br /> Safety Code, and San Joaquin County Environmental Health Department(EHD) requirerents. It the use of the <br /> commissary is discontinued,the permit holder must notify the EHD- Failure to no*this office may resultin permit <br /> revocation/a"nslties. 9 <br /> Signature <br /> L o�/�y t E�/lt�l `t '— Date <br /> 2s Tdbe-,- lamed W C{? INIiSSARYOItERfOP€Ri4OL __•:: <br /> Commissary Name <br /> Address ' E Vkon,fA.v,a van Bus. Phone SCA • 14 L U - 70 <br /> City �� i< n 71p X35205 OwnerlOperator �,na on Q'-1 t <br /> Check all appropriate services provided: <br /> Wastewater disposal U&comparlrnent sink :- �B�iicai hook-ups <br /> eolid waste disposal � Food preparation 1 let and handwashing <br /> Hot&Cold water for cleaning C3 Store refrigerated food le water <br /> lij Store dry foodisupplies M110vemight parking Vehicle wash <br /> k, hereby state that the information 1 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 ply with the condi o ibis agreement, or if this agreement is modified or cancelled, the <br /> commissary wner shall noiiry the me�tatety <br /> Signature Date <br /> 3, To be completed by,:t16eN /1=lEAM -l;W' dicfiori outside *��. <br /> The commissary is located 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 /> RENS Signature Date <br /> 1868 E.Hazelton Avenue 1 Stock mn,California 962051 T 209 468-34201 F 209 464-0938 i wwwsjgov-orglehd <br />