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7s 6 <br /> SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility e 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 /> Business Name71n ,, �s .5;,, �cr 4 Z C Lic.Plate# 0 9 �C <br /> Owner/Operator Name S-A,a//� �c / <br /> Business Mailing Address <br /> City /`lf�o�2J><t State�ZipBus. Ph. It. Ph. <br /> I (-�-\-( 2�\a fi ( C 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 penalties. <br /> Signature <br /> a�,k �...Date <br /> 2 To be compl f to .by COMMISSARY OWNER/OPERATOR <br /> Commissary Name_ 'pa ffliq -7-13 FA# aOA 7 49 3 <br /> Address Bus. Phone <br /> City L444 bC 20 Zip q S_S w er/Operator f'-2V tr <br /> Check all appropriate services provided: <br /> dWastewater disposal 0 3-compartment sink Electrical hook-ups <br /> ga Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> ❑ Hot& Cold water for cleaning ❑ Store refrigerated food VPotable water <br /> ❑ Store dry food/supplies Overnight parking CSI'Vehicle wash <br /> I �Vg }_on5.g- Lb _,hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledgefand 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 own hall no a EHD immediately. <br /> Signature Date �- <br /> 3. To b com leted 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 />