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I <br /> SAN 1 OAQ U I N Environmental Health Department <br /> COUNTY <br /> r <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 /> ((� <br /> /-% <br /> Business Name j-f;V -F% © C.—S) ' f C14- S- Lic.Plate# lu L 6) <br /> Owner/Operator Name_ IF rn�/ 40'j <br /> Business Mailing Address M p S a'pq <br /> City /QA �State-Ga-Zip9us. Ph — /& Ph. <br /> I. T WIM it r;!o&+✓' hereby state that the above information is current, true and correct to <br /> the best of my kno ledge 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 Date <br /> � <br /> Z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name W tAls�Z FA# <br /> Address14 ' OL d j Bus. Phone,0 Z— qJ41�e <br /> City ZiptZOwner/Operator ¢ <br /> Check all appropriate services provided: <br /> I� astewater disposal ❑ 3-compartment sink ■ lectrical hook-ups <br /> ® Solid waste disposal 13Food preparation Toilet and handwashing <br /> 13 Hot& Cold water for cleaning _3 tore refrigerated food Votable water <br /> 13 Store dry foodisupplies Q Overnight parking Vvehicle wash <br /> I, -64 ^JR. R/YI hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,a d 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 notify th D immediately. J <br /> Signature � Date `T� /z 3 <br /> 3. To becompleted feted b the ENV HEALTH jurisdiction 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 />