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SAN l OAQ 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 3. <br /> 1. To be completed by APPLICANT <br /> - <br /> Business NameR A"I CR Lic. Plate# <br /> Owner/Operator Name ASV A M��JT2A 'FLtffS S z() <br /> Business Mailing AddressWHITEV— I& <br /> City I ",,pp\,, C� StateaziBus. Ph � AIt. Ph. <br /> I, f' I j K F , 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 and nalties. <br /> Signature A Date <br /> 2. To be completed^lhby COMMISSARY OWNER/OPERATOR <br /> Commissary <br /> Name 1 v o I v A1 N �F�Ay#� /� <br /> Address 1 I ��l' U N 16 N S S1 Bus. Phone ) l 2M7J <br /> City S�(/U0 N,(/Nip IS U tv Owner/Operator AOT- 11 9-NW <br /> Check all appropriate services provided: ' <br /> astewater disposal 3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> Store dry food/supli�eps� rl Overnight parking ehicle wash <br /> R �� ► `�V , hereby state that the information ave 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 oWtify the EHD immediately. <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Siockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> f�t�SLj�QIg�p <br />