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Signature <br />SAN JOAQUIN <br /> Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Compete,9 SCC1i0S 1 and 2. if commisSary is located outside of San Joaquin County also compicto section 3. <br />'I. To be corn <br />Business Name <br />feted by APPLICANT <br /> <br />-HT() k ho Ltt Lie Plate ti 4tA <br /> <br />Owner/Operator Name ly <br />Busiess Mailing Address <br />City - StateZip Bus. Ph.(2.A)Li_11-9)L'Aill <br />hereby state that the atxyde infc.Irmation is =rent. true and correct to <br />the best of. my knowledge and agree to utilize my approved commissary in aordance with California health & <br />Safety Coda, and an Joaquin County Env:ronme-ntol Houlth Deportment (EHD) rcquirements. if the use of the <br />commissary ic Cis ontirued. the permrt holder must notify the END. Failure to notify this office may result in permit <br />revocation and nalties. <br />Date CI IC141`21 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Comntssary Name CC:11 ve\ 7 F 6; eZ 1/6) TILL FA il 2_0 (i • //' 0 <br />Address -2-.).S_5 U. G qt. le4 A.,( Bus. Phone 1...01-'IY/ • ZS 7 <br />City t-CC.1 Zip cL5Ltid Owner/Operator Al be,c-6A..Lrq c e <br />Check all appropriate services provided: <br />Alt. Ph. <br />1,WHAX ti \u <br />1: Wastewater disposal <br />Id Solid waste disposal <br />*Hot & Cold water for cleaning <br />0 Store dry food/supplies <br />1. Atbe„Vc <br />commissary owner s <br />Signature Date _j/ 202- y <br />Date <br />'ii 3-compartmentsink <br />O Food preparation <br />O Store refrigerated food <br />*Overnight parking <br />1?(Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />41.C.Vehicle wash <br />, hereby state that the Information I have provided is current, true and <br />correct to the bes t of my knowledge, and meets the California Health & Safety Code requirements. If the food facility operator fails to compty with the conditions of thls agreement. or if this agreement is mocfrfied or cancelled, the <br />oiThej,13immediately. <br />'1 3. To be completed by t ENV HEALTH Jurisd lotion o14sYletif San4Oacitfin Co. <br />The commissary is located in 0/Minty. The above (OM facility meets the <br />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. <br />REHS Signature <br />leibd C Hacelton Avenue EtOCklOrl, California 96206 I T 209 468-3420 I F 209464.0138 I vAvw.sjgov.orgiehd <br />• <br />FROSL\-1-