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€ OA UIN EEnvi ron mental Health Deoartmen°L <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 7 and 2. If your commissary is located outside or San Joaquin County also complete section 3, <br /> Business Name �� � � t } �Li <br /> c. Plate# �V��C� ` <br /> Owner/Operator Name ckS c-D V--'eZ <br /> Busines-sr M <br /> ailing Address (71LVI S l W <br /> ^)State 0�--Zip9'1:_�,--7 (0Bus. Ph.Z f 7� <br /> � l`T'4� Alt. Ph, <br /> 1` hereby state that the above information is current, true and correct to <br /> the best or 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 �/I C fi 6_D i pz(tZ.� Date 02_— t F r <br /> it4f - <br /> C O m m'is sa ry Name <br /> FA# <br /> Address Bus. Phon 2-ZLI - <br /> 2--e rL H <br /> City Zip ZL--�� <br /> Owner/Operator �Cr, <br /> Check all appropriate services provided: lj <br /> Wastewater disposal X 3-compartment sink <br /> �C )3f Electrical hook-ups <br /> z�€ Solid waste disposal -Er'Food preparation <br /> Toilet and handwashing <br /> ��, Hot& Cold water for cleaning Store refrigerated food Potable water <br /> � yore d � <br /> ry foodlsupplies Overnight parking Vehicle wash <br /> te that the information I <br /> correct to t and <br /> 47""he best of knowledge, and meets hereby <br /> Calir`oana Health &Safety Coderequirements.ve rovided f s Tuhre a true <br /> operator fails to comply with the conditions of this agreement; or if this agreement is modified or <br /> cancelled, the <br /> commissary owner shall t'd h�Q��m <br /> mediately. <br /> Signature J <br /> Date <br /> The commissary is located in <br /> aboveCounty. The facility the <br /> commissary requirements in California Health & Safety Code. The above checked ervices areava e l b ea- the <br /> above commissary. ?lease notify EHD if the status of their operating permit changes. <br /> REHS Signature <br /> Date <br /> :ockton, Ca irornia 9_5205 T %'9 '08-34^- 2 464-01 _ <br /> -c.. 09 38 vr,^J�.•v.s_yCv. <br /> Kzs Q)339 <br />