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SAN JOAQUIN Environmental Health Department <br />.1 <br />1 <br />AH Ph <br />Date x 3 - < <br />Ddlw REMS 5»jntiluio <br />i I <br />I <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />i <br />i <br />Q' 3-compartmenl sink <br /> Food preparation <br /> Store refrigerated food <br />( O Overnight parking <br />________ _ ______ Dale____________________________ <br />rifo b« <br />Thy W»nmiss«ry te locaicd in_____________________________County The above food tsoMy meet* w <br />cornmwiry nKWlremenia In Cnlifomla Haalh A Safety Code The abow checked MfMbas ant avaJabie at the <br />c/>mrnl**afy Ploeie notify EHD if the stalus of their operating pemvl change;, « <br />IJC Plate « > <br /> Electrical hook-ups <br /> Toilet and handwashing <br />Sk Potacie water <br /> Vehtdewash <br />, hereby state that the information I have provded is ciiment irue and <br />2 To be completed by COMMISSARY OWNER/OPERATOR <br />Bus. ~7 'LQ)~L2& <br />Owner/Operator r:«n v <br />1W8( Hu/i hoii Awinii'| SI.wH.mi i. .iblniiiM U'^05 | I 2O«468 J42O| F 209 464 0138 | .v*v, s;,jov ohj rM <br />Cc ! ,-u'nj 2 if n'l/r currvnissivy in heated outnf S»n Joiw<) Count/ »ho -.’^cr^on 'j <br /> ! i~To be completed by APPLICANT <br />BusnessNameQ\ t1 / ikn /.'p/ntj I It <br />Owner? 0 pe ra to r N a me J r.i < lz/K7<______________________ <br />Bu&ness Mailing Address ./.Z'F 5/ . M ^/C'7 <br />; Slate '7/ Zip Bus Ph 7/-7' J/jY <br />I .~ r ’z >________________, hereby stale lhal the above information is ajrnrrtf. ime •nd ccrrea to <br />me best of my knowledge and agree to utilize my approved commissary in accordance w«h CaMorrw Henn 4 <br />Sk’ety Code, and San Joaquin County Environmental Health Department (EHD) requirements ff the use c9 ’b* <br />comm'ssary ts discontinued pie permit holder must notify the EHD Failure to notify this office may rwuY <n <br />re^ccatjon and penalties <br />S*g rat ure__________ZZ" <br />Commissary Name •./Zc’-r A7’- <br />Address. i"7^| SZ-Vc- £ <br />C>ty Zip Q- <br />Check, ail appropriate services provided <br />3. Wastewater disposal <br />PI Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/suppbes <br />conect io lhe best of m/ knowledge and meets the California Health & Safely Code requirements W the food tadty <br />opetalor tails to comply with the conditions of Ibis agreernenl, or if Hus agnsemenl is medihed er canceled the <br />commissary owner '.hui* notityTty! EHD imnurduUd^ <br />Signature_ ------------.Dale.____f?(p '"Q-. ___