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i <br /> SAN JOAOUIN Environmental Health Department <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 completed bAPPLICANT <br /> i <br /> Business Name n��1 C )IX- r nY�G� N <br /> 1 A/}kjLic. Plate# <br /> Owner/Operator Name h <br /> 2 <br /> { <br /> Business Mailing Address ��(( ^' U'4 � \ <br /> Cityr�77SIG� c\1 StateQ-T)Zip�9U6 Bus. Ph. 61 90"3 - Mt�,Alt. Ph. <br /> I, rJl( YYiI(� LcwZ-' 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 f .. Date V <br /> 2. To be com let by COMMISSARY OWNERIOPERATOR �t <br /> Commissary Name_L FA# 002 7.4 9 3 <br /> Address (D ,219 1 Nlqr' A n1Bus. Phone ,2e) <br /> city W brr pZip__9S 33Owner/Operator Fewt <br /> Check all appropriate services provided: J <br /> Id Wastewater disposal O 3-compartment sink 0 Electrical hook-ups <br /> ® Solid waste disposal 13 Food preparation 61Toilet and handwashing <br /> ® Hot& Cold water for cleaning C3 Store refrigerated food VPotable water <br /> © Store dry food/supplies Overnight parking CSI Vehicle wash <br /> I, Sq ,9 = _nnS_f_- 4 _, 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 ILI 7 2. <br /> 3. To b com leted by 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 />