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i <br /> Environmental Health Department <br /> artment� JOAQUIN a <br /> COUNTY — <br /> (� fit•5s wows here. <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 by::ARR.LICANTV , <br /> Business Name J!� Ik r LIS TjQ C1 -Lic. Plate# `-A Vc r� <br /> Owner/Operator Name Ck '�� <br /> Business Mailing Address Q <br /> City ro 1 State Zipf�3us. Ph. -5,3 �►. 3 - 7 � <br /> I, Ci_ <br /> tl 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 /> Signatur Date 3 <br /> 2. To be com let by COMMISSARY OWNER/OPERATOR " <br /> CommissaryName_L FA# �C7x 7 9` <br /> Address Tp 2 L)d _"t�Ar` !'-1 rJ Bus. Phone akl - 7J 7-- _9te <br /> CityPZip q 1Z 7.7SO Owner/Operator �'".P✓Y.L <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink Electrical hook-ups <br /> Solid waste distosal ❑ Food preparation ICS Toilet and handwashing <br /> ❑ Hot & Cold wat r for cleaning [3 Store refrigerated food VPPotable water <br /> 13 Store dry food/supplies W Overnight parking C Vehicle wash <br /> I, `� yr�Sj:--LL , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge and 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 ' e EHD immediately. n <br /> Signature Date / Z- <br /> 3. To b com leted b -the ENV HEALTH jurisdiction;outsideof San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary require ents 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 />