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u'CUVED <br /> JAN 11 2023 <br /> SAN .J OA Q U IN Environmental Health b6partment <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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(n <br /> Business Name �rj �� p u.--d� � . S Lic. Plate# <br /> Owner/Operator Name_ '✓VI vn <br /> Business Mailing Address YY1 " S CV-49 <br /> City—f-4aQState ',Zip 9us. Ph — 41 Ph. <br /> l �JL"IMT TiA� 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 Date <br /> ,/ // Z .7, <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name /q 1-, �} FA# l Q <br /> Address a0L jvpqrl nj R� Bus. Phone 0n7 <br /> City ¢_Zip�_Owner/OperatorQ*/y ��¢ o: ' <br /> Check all appropriate services provided: <br /> (� astewater disposal ❑ 3-compartment sink ■rFlectrical hook-ups <br /> Sol <br /> id waste disposal ❑ Food preparationC! 011et and handwashing <br /> 13 Hot & Cold water for cleaning ❑ tore refrigerated food Votable water <br /> 13 Store dry food/supplies rT Overnight parking Rd Vehicle wash <br /> I, _ �6'IS 44R 16&M hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge,akfd 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. <br /> Signature Date <br /> 3. To be com feted by the ENV HEALTH jurisdiction outside lof 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 />