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SANsJOAQUIN Environmental Health Department <br /> COUNTY-- <br /> r <br /> Greatness grows here. <br /> t]tlX=lroyRd D1S01'itlstlu! <br /> � ar3 <br /> 145 <br /> COMMISSARY AGREEMENT aumlWock,CA95310 <br /> Mobile Food Facility • Caterer L.- — 209-04- 06° <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 TDof S M D ryl (ALic. Plate# 4 u o 9 773 <br /> Owner/Operator Name 5q ✓0. R'05 a S G a f'o iCt <br /> Business Mailing Address K 104 4; e WC cl <br /> City Mu�✓leca State�Zip 45336 Bus. Ph. (Zr�l�Z75-31Z7AIt. Ph. <br /> I, SRvR ga!54-; Ga e-0145 hereby 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 a a iw. <br /> Signat Date <br /> 2. To completed by COMMISSARY OWNER/OPERATOR gj /,/LJ y�jS' / C'✓YY�-C�S'GtI'c <br /> Commissary Name I �J �J r IV-/)C, FA# <br /> Address (clS S, kl l tror. Bus. Phone Za �/- Zoo a <br /> City �u✓�lJ ( Z p Owner/Operator <br /> Check all appropriate services provided: PZ� o n-S 944 e)q orz ✓ <br /> Wastewater disposal P 3-compartment sink 29 Electrical hook-ups <br /> Solid waste disposal td Food preparation Toilet and handwashing <br /> 14 Hot&Coldwater for cleaning 10 Store refrigerated food Potable water <br /> M Store dry food/suppli/gs &I Overnight parking Vehicle was <br /> I, �YY)o ,I /�✓c+` , hereby state that the information I have provided is Sgly <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. I <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modifiedcommissary ow r s La ti ediatelSignature Date �6 ' ZD <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San J MARY-KATE COOK <br /> Senor Environmental Health <br /> The commissary is located in i A sJt`U �-A u`a County. The above food fSpecialist <br /> commissary requirements in California Health & Safety Code. The above checked services are ENVIRONMENTAL RESOURCES <br /> above commissary. Please notify EHD if the status of their operating permit changes. Environmental Health Division <br /> G 3600 Cornucopia Way,Suite C <br /> 95358-9494 <br /> REHS Signature �� q' Date I� Modesto, 9)525 6713 <br /> Direct:(209)525-6713 <br /> Main:(209)525-6700 <br /> 1868 E. Hazelton Avenue ckton, California95205 T 209 468-3420 F 209 464-0138 Cell:(209)505-7366 <br /> I � 1 � Fax:(209)525-6774 <br /> Email:mkcook(&envres.oro <br /> www staocowaly= <br />