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SAN JOAQUIN <br />—C U N T Y— <br />Grentness grevil herr. <br />Environmental Health Department <br />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 />TO be completed by APPLICANT <br />Business Name T A CO$ A aulit butzg Lic. Plate# 7 55 R. 1 <br />Owner/Operator Name .5C6e 1.„015 g 6 9.,,p_r4A-- <br />Business Mailing Address I. AC) 5 u-t--9.49 A v6 <br />Cy 54661=4 StatCA" ZipV_AtBus. Ph2COALT-LY. tagAlt. Ph. <br />Vi5 /1-txrcrok. C,. 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 (END) requirements. If the use of the <br />commissary Is discontinued, the permit holder must notify the END. Failure to notify this office may result in permit <br />revocation and penalties. <br />SignaturS559_ cii5 Perrrtzt C Date OLVe /202Lir <br />rripleted by COMMISSARYOWNER/OPERATOR <br />Commissary Name 4\ Co v-rvele-c-i ct Q FA# <br />t.)...x.).1 Bus. Phone 2_(:)ci — — S70 Address -c-t0 . <br />City --(3c..irc.\-c.--rN Zip qS2_0 C Owner/Operator (-'4 " On.ir \Q--n-e-A4- <br />Check all appropriate services provided: <br />Itt Wastewater disposal a.3-compartment sink Electrical hook-ups <br />jZf Solid waste disposal D Food preparation Toilet and handwashing <br />.& Hot & Cold water for cleaning D Store refrigerated food Potable water <br />14. Vehicle wash <br />A4 0 8Ct raitta , 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 owner shall ,ify the END immediately. <br />Signature Date tft(g '2-9 <br />igiEral i 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 comrpissaiy, Please notify END if the status of their operating permit changes. <br />D Store dry food/supplies ISE Overnight parking <br />RENS Signature Date <br />' <br />ifaie4to;iA4eiti'm Slot ri, California, 952051 T 209 468.-3420 I IF 209 464-0138 I www.sigov.org/ehd