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SAN 10AQUIN Environmental Health Department - ---COUNTY__ COMMISSARY AGREEMENT Mobile Food Facility ♦ Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. 1. To be completed�nb APPLICANT , / Business Name i;i�/"I�J 4 CAL E�,1 0 0 L Lic. Plate# y_ V �3/ Owner/Operator Named)if CbotcY JK cA5i&c z -J Business Mailing Address_a(v,2 L Cf A-14 M) 37 City_5Z CC��Gr:U State�4 Zip qVCd Bus. Ph2o9 )71Y— �( (�- Alt. Ph. I, J e CA,51Z6 4-), hereby state that the above information is current,true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit revocation and penalties. P, Signature0_ Date D 1,2911,20.2-3 2. To be completed by COMMISSARY OWNER/OPERATOR Commissary Name 0)1110/V ('47L iQ/UCS DUCK ("CA)-T1_--K FA# Address_1?1 7 U U�O AJ S-7• Bus. Phone 20 2_9 Y-S L// CP Cit y 5-70CK t U AJ Zip gSaO(,.- Owner/Operator 4C% 7 eAOO Check all appropriate services provided: W 5 fbCAb t= 0 Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups ® Solid waste disposal ❑ Food preparation 0 Toilet and handwashing M Hot & Cold water for cleaning ❑ Store refrigerated food 1� Potable water ❑ Store dry food/supplies ❑ Overnight parking 13 Vehicle wash 1, 6C, 7/)C/g1)0 , hereby state that the information I have provided is current,true and correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the commissary ow__:Oner hall/noo�' y e EHD immediately. Signature i��s(1��` Date 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue I Siockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd