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SANvaJOAQUIN Environmental Health Department <br /> –COUNTY— <br /> _. . <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:com leted b ' APPLICANT' <br /> Business Nameh stir S rrc%a LLC Lic.Plate# `/,e p L/ <br /> Owner/Operator Name��Sf-e Av;/ti <br /> Business Mailing Address v_ 3/ S <br /> City�State ZiprBus. Ph. It. Ph. <br /> 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 ( AKSAK6 a ajoolxl�r l Date 1 –? -"-23 <br /> 2.To be corn let"' .bCOMMISSARY.'OWNER70P, --'IOR <br /> Commissary Name_L FA# 000 7 49 ?_ <br /> Address Hpage-LH6 nl Bus. Phone X09 - 7/2— ( QUA <br /> City Alp Zip �ZOwner/Operator tit�'.�V.L RbM <br /> Check all appropriate services provided: J <br /> ,(Wastewater disposal O 3-compartment sink M Electrical hook-ups <br /> ® Solid waste disposal O Food preparation Toilet and handwashing <br /> 0 Hot& Cold water for cleaning OStore refrigerated food [Potable water <br /> 0 Store dry food/supplies F$/overnight parking GJ Vehicle wash <br /> JThereby 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 7 Z- <br /> 3. To b ';cornfeted b. the ENV HEALTH 'urtsdiefion`outside of San Joa uin 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 />