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SAN ;JOAQUIN Environmental Health Department <br /> --C C)U N T Y <br /> ' Grrotoeis VIC.,.. i <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 Caterer <br /> axrlP�;e sattion 3. <br /> Comy*4v seasons t and 2 K yr�in car+rmssary is lbcaW aAsrdo of Ssn.Aosgr�n Caurf Y efsc <br /> Business Name ' �[ ,- ��� __ IC plate falD <br /> OnIvKA4 <br /> __ Q- .tLL <br /> Owner/Operator Na a I✓l,<��. •4 z <br /> Bua�,� <br /> Mailing Address <br /> ,/� GAAll. Ph._- <br /> Ci S1ateL�Zip Sb O sus. Ph/.b v, — rxereby state that thn above rnformauon is current,true and ourreet to y <br /> Ile best of my knowledge and agr" to Witize my Opo"rvul rjoew-issary r, acrrzianoe a+th C0110 is Heasith & <br /> Saloty Coda,and San Joaquin County Enviranmontal Health Department fEHM requrrornenis. If the use of the <br /> co"rissnry is(isctatmed.Iho perm•t holder must na ly the END Fa inure io hot,fy tnrs office may rescan n permit <br /> revocation andLpenaltle n <br /> Signature_ - —- _gate Z -Af <br /> .�d1 COMMISSARY OWNER/OPERATOR <br /> �om �s�y Name . r -nt��t L14) - --FA#�-- <br /> Address. �� L2`? Our,Phryte ' t>�, yG <br /> city ed0porator <br /> b i Check all appropriate servom provided <br /> im Wastewater disposal 16 3-compartment sink t4 Electrical hoots-ups <br /> Seiki waste disposal 13 Food preparation Toilet and handwashing <br /> } Hot&Cold water for cleaning O Store refrigerated food M Potable water <br /> D e dry food! pplies Is Over ilght parking Vehicle wash <br /> Rr <br /> f, p NIYi _,hereby State that the�nlormaGnn 1 have provided is Current,true and <br /> c ltd t8 of mY krtovrlo0ge. meats the California Health&Safety Code requirements. It the loot!facility <br /> operator fps to copfpy Mrith the r,s of pis asrft nerN Or ,t this agreement is modified or cancelled, the <br /> cormis ry ot-gprshalf notify EHD Irmrrks tar . ? <br /> Dale <br /> MEN" r ENV HEALTH ju sn di on outside of San JDacluln, o: <br /> The Commissary is located in ---., <br /> cOmmis County, The above food fac ity meets the <br /> sery requirements California Health& Safety Code. The above checked services are available at the <br /> atone txxnrrtrssary. Please notify FHd if the status Of their OW0119 pefmit changes, <br /> RENS Srgriature <br /> Date <br /> 1868 E.Hazefton Avenue I Stockbri,California 952051 T 209 468-34201 F 209 464-0138 1 WWW, <br />