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SAN JOAOUIN <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name Lie. Plate# <br />1 A <br />Date <br />Owner/Operator, <br />'ehicle wash <br />.Date. <br />3; Tobe in Co. <br />REHS Signature.Date <br />r 209 464-0'5 38 j v.w.v.s gov.cm.-end <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. The above checked sen/ices are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />Environmental Health Department <br />yZEiectrical hook-ups <br />p^Toilet and handwashing <br />JM^otable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />Commissary Name <br />Address <br />City Zip <br />Checkin appropriate services provided: <br />|0z^/y^stewater disposal S/S-compartment sink <br />5/Solid waste disposal ^O^Food preparation <br />Cold water for cleaning (^Store refrigerated food <br />iZKstore dry food/supplies [pz6vemight parking <br />I, . 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 />S i g natu re________________________________ <br />1. To be completed by APPLICWT <br />T A G <: Tc <br />Owner/Operator Name <br />Business Mailing Address L-k ‘TTJ" <br />City Estate ^7>zip ^-^Abus. Alt. Ph.^7^*0 M <br />•>L_L_Lj • n , 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 />_________FA#_______________________ <br />Bus. Phone_ <br />1868 E. Hazekon Avenue Szockton, California 95205 i T 209 468-3420