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SAN J o Q Q U IN Environmental Health Department <br /> ---COU N T Y-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facilityl, Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> APPLICANT <br /> Business Name VoOs�er5L-�-� <br /> Owner/Operator <br /> Name <br /> Business Mailing Address an!J� z C cyaW{1� PA <br /> City�S�DC��(?)i�l State} Zi " <br /> p 'I S oZ(S Home Ph. Bus. Ph. <br /> I, (:�I l/LQ4a '<'-kr✓l , hereby state that the above information is current, true and correct <br /> to 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 disco inue , the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and na ies. <br /> Signature U�lw Date v a-— <br /> To b'e horn le d b` COMMISSARY`01NNER/OPERATOR` <br /> CommissaryName Lin Coomisac w Pode,,lro FA# <br /> Address 1Z\\ S. :14" fS jme,�- Bus. Phone ULOq)'33%—3663 <br /> CitDesly Zip q Ell l Owner/Operator Lo lcl 9-ocag� Comm i s5c�ry <br /> Check all appropriate services provided: <br /> Wastewater disposal 10 3-compartment sink Electrical hook-ups <br /> P <br /> Solid waste disposal 0 Food preparation rA Toilet and handwashing <br /> Hot & Cold water for cleaning 150 Store refrigerated food W Potable water <br /> Store dry food/supplies 0 Overnight parking M Vehicle wash <br /> 1, rbc. (_diS C,N:27 , hereby state that the information I have provided is current, true <br /> and correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food <br /> facility operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, <br /> the commissary owner shall notify the EHD immediately. <br /> Signature Date IV/ 18/12- <br /> 3.'Tobe ,Corn leted b ' �theENV;HEALTH 'urisdicti <br /> K ,- m cn cn 3 <br /> The commissary is located in d _ .. : a o 0 <br /> commissary requirements in California Health & Safety Code. The o N z <br /> above commissary. Please notify EHD if the status of their operating 8 ch—�- 0 0 � m 3 a <br /> xQIccr N (Do� 34 3M <br /> 0 0> -4 cnw � (Dn <br /> REHS Signature - �, _ - - � o . � o,p <br /> < AppOv - , <br /> m �m p <br /> 1868 E. Hazelton Avenue t ckton, 'alifornia 95205 T 209 468-3 3 N W v� o oEX <br /> d <br /> r j M <br />