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P( os'AD15 <br />SAN JOAQUIN <br />- cc-,L,NTy— <br />"virorimental Health DePattrIent <br />COMMISSARY AGREEMENT <br />Mobile Food Facitity, CaZerer <br />Is /coifed uots.ile cl San .Aosquirp County aiIso comP00 section 3, Cory, 0 —rhete sedions f end 2. If yaw- commissary <br />_ — --- —____ <br />1 . To be completed by APPLICANT _ : <br />Business Name 701/114-41-----R---4( l t 4* l' r 2 ___LiO. Plata 00- '/',4 tIe7 <br />°Wner/Operator NameIa-r\'— <br />Business Mailing Address t 0 6)-0 \-VD <br />CitY LA' Zip_ Cl‘Bus. Ph ci t a oL- `1393Ait. Ph. - 1020-.12-S 2 <br />t\ice , hereby state that the above information is current, true and norrect to <br />the best of my knowledge and agree to utilize my approved commissary in accordance .ivlth California Health & <br />Safety Code, aria San Joaquin County Environmental Health Department (LH()) requirements. IT the use of the <br />oammissari is discontinued, the permit holds must notify the EHD. Failure to nobly this affect may result in permit <br />revocation and penalties, <br />Signature --)-1..cira rv-C- v'\c, C - <br />12, To be completed by COMMISSARY OWNERIOPERATOR 1 <br />Commissary Namo e ( <br />Address <br /> /-rfo.,[j,,,-, <br />..7,r_c .47 / &wild ./4/4?_ &Ls_ Phone Nil j T /-,e2 J77 <br />City_4z4, Zip 4- 7. ; 5 - 2 1 (Zio Owner/Operator 44-•Pf/i) <br />Check oil appropriate services provided. <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />jIr Vehicle wash <br />I./14474 lt..„---re'z hereby state tnat the information I have provided is current. true and <br />correct to Vie bes': of my knowida,ge. and meets the California Heald] & Safety Coda 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 shallflotify ;he E-jmlivedlatitly. <br />Date_ //-), Signature <br />I 3. To be completed by theENV HEALTH jurisdon outside of San Joadilin Co. — _ <br />The commissary is located in County fnii above food faciiity meets commicary requirements in catitomie Health & Safety cede, The above checked se-vLes are availatilo at tho aoove commissary. Please notify EHD if the staus of their operating permit changes. <br />REHS Signature_ <br /> <br />__Date <br />7858 E. Hazelton Avenue I StocAton, California U5205 I T 208 468-3420 F 2 464-0138 I ''vww-slgov org/ehd <br /> <br />pi Wastewater disposal <br />pc Solid waste disposal <br />Hot & Cold water for caaning <br />0 Store dry foodis;upplies <br />3-compartment sink <br />0 Food preparation <br />0 Store rafngarated food <br />PI Overnight parking