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<br />Environmental <br />- <br />Environmental Health Department S A N <br /> <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 />FA# <br />iMiectrical hook-ups <br />UIroilet and handwashing <br />a-table water <br />214hicle wash <br />Signature <br />To be completed by APPLICANT <br />Business NameCinui‘( 105 1 ii ei‘( Hc. Plate # 53 5 <br />Owner/Operator Namerj r V\ r\ )‘\ \r* y() <br />Business Mailing Address /233) \WV\N-\e, • 1,661 Ur 2--`-1 2- <br />City W‘ State(Fr Zip 4d4? Bus. phOwt\ qct 532S- Alt. Ph. <br />I, er w'n a_ <br />Date <br />To be completed by COPARY OWNER/OPERATOR <br />, 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 (EHD) requirements. If the use of the <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature <br />Commissary Name -11e.e,fee--1. Z.S.Dcr/-% <br />Address (01 Z/i .5- ----€4ert.TAil-e' Bus. Phone Ce) <br />City (--9' Zip- ."(5-z. SY Owner/Operator Airyce, in, Gel-s-e_ <br />Check all appropriate services provided: <br />astewater disposal Te‘compartment sink <br />drSclid waste disposal ood preparation <br />Hot & Cold water for cleaning ZgOre refrigerated food <br />72ri'ore dry food/supplies a/6;ernight parking <br />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 notify the EHD immediately. <br /> Date 3 2 <br />3. To be completed by: •theEtilktaNel_T::, ju1isdietion.900Nitsap Joaquin Co. <br />The commissary is located in County. The above food fachity meets :7e <br />commissary requirements in California Heaith & Safety Code. The above checked services are available a: the <br />above comrnissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />1868 E. Hazeirch Aveh,:e for-7:a 95205 T 2C468-3423 F 209464-0138 www.s,gcv.c7o,e7t