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v Env. z�►thl MoNT <br /> -4-2-00. "' SAN 1 O AQ U I N Environmental Health Department <br /> ------COUNTY- -- - <br /> COMMISSARY <br /> ----COUNTY--_ _COMMISSARY AGREEMENT <br /> Mobile Food Facility + 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 /> Business Name M p\ 1c"1 N 1, l 1 F N Lie. Plate#C <br /> Owner/Operator Name 1 Sy S K N T-0 N 10 M E` �(,LF N D E � �� ES <br /> Business Mailing Address Q w )i MKS, wl)D V) �V E <br /> Cityc{y `(�'�(,� State�Zip d� us. PhIkQ�6(j�3--,N3#Alt. Ph. <br /> I, I,5 VS �s V=1 KS 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 h Ider must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. Q ��,,11 n <br /> Signature Date D$_ -Lci / —L3 <br /> 2. To be completed b CO N ISSARY OWNER/OPERATOR <br /> Commissary Name V NW n IENV N�E� 7V Cf—UCtN 1 FIFA# <br /> Address 110 5 V N 1 ON S1 Bus. Phon� `�- 211 <br /> O) r 5 q ( LO <br /> ff <br /> City l,M N _Zip " ICD U � Owner/Operator ( M M)IO -T t �Z f� J) <br /> Ceck all appropriate services provided: N o �-� C-1 E <br /> Wastewater disposal E3 3-compartment sink E3 Electrical hook-ups <br /> Solid waste disposal p Food preparation �1l Toilet and handwashing <br /> Hot & Cold water for cleaning [3 Store refrigerated food ® Potable water <br /> 0 Store dry food/supplies E3 Overnight parking ;"Vehicle wash <br /> I, T1 F=b�tlJ , 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 ow er s all otif the EHD immediately. <br /> Signature Date ZL <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of 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 /> 1868 E. Hazelton Avenue I Siockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />