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• 05 Li SLI ) <br /> S A N cM A O U I N Environmental Health Department <br /> COUNTY <br /> �,-,:z r' Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility♦ Caterer <br /> Uorrplade aecb m 1 and 2 if yow canwussary is lbcafed outside of San Joagrdn Coudy also cornplebe section 3. <br /> MT.1 <br /> Business Name_pjA Vq i- r o �.4 nair-Ptate# l 9 S�1 aG <br /> Ownerl0perator Namef f IZ A Q —�T' C—P d u Iy1 W6 <br /> Bwffms nag Address A,5 �a Z)A iVE <br /> City Stwe-Q,ZP9Szl�-Ph.o-ay AS? QRyym. Ph. o105 -Z 7L 47Sy <br /> 1. i�-S-fg t' �t�.e�t�u/�� .hereby state th <br /> e at the agave is amait,true and cared to <br /> the best of my inrowtedge and agree to utifte my approved commissary in accordance wkh Caiiforda Heeilr & <br /> Salary Code.and San Joaquin Courtly Erniranmental HeeNh Depa rknent(EHD)r'equrremicts- U the use of the <br /> oorrunissary is wed,the perrrrit holder roust naffy the EHD. Fatiure to nodfy this affirm may result it permit <br /> revocation and penalties. <br /> Date <br /> MEN <br /> Camtissary Name ` y- a� N I SSU r�� FA# 0 V51 95ce <br /> Address- -2-1 Bus. Phare 2z 56 S <br /> City Ex Zip 9 y sA S ownedoperator <br /> Check ala appropriate services provided: <br /> UlWastewater disposal X7'3-oorrtperirnant sink fid"Electrical hook-ups <br /> P- Sold waste disposal Food preparation 41 Toilet and hamWashing <br /> O'Hct ff Cold water for ening 018tore re*Wrated food /D Potable water <br /> p-,S`tore dry ftAh uPPlies Or Ove parking 9%'vehide wash <br /> 1, S,'614(1,0-4 .hereby abohm#Wthe irrborrrstion I havepnovidmd is current true and <br /> correct to the heat of my kn wiedge,and meets the CaKarda Heallh 1!i Safely Code requirements. If the trod ibcRy <br /> operator falls to oornpiy whh the conditions of this agreement. or if oris agreement is modified or oarroetied, the <br /> con rdwary owner dial notify the EHD i medWely. <br /> Signature= <. �1 t / g z3 <br /> The commissary is located in G u► r+ rAY. The shave food y meets the <br /> oormnamary requirements in CWWmWa Health & Safety Code. The above chacked.servioes are evelable at the <br /> above comm issm y. Please notify EHD if the status of their operaft pemat changes. <br /> REHS SignatureLb[ti4oDate h O IN <br /> 1868 E_HaaeWn Avenue I Stoddon,Caf mita 952051 T 209 46&342D 1 F 209 4640138 1 www.sjgov.crgfehd <br />