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RECEIVED <br /> SAN JOAQUIN Environmental Health @L i5A"t.I <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility , Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin Count} also complete section 3- <br /> 1 . To be completed by APPLICANT <br /> Business Name ` 6A (Z��� 1 �! ON Lic. Plate G L 4 q 6 Z <br /> Owner/Operator Name E� ►C C 0.rc fe <br /> Business Nailing Address Nil Oonuki (,_i L <br /> C'ty StateZip�S?,c� Bus. Ph. I-Uq 3 9501 Alt. Ph. <br /> I. VV C y 1PLr L 1 W , 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 /> SignatureDate 9 <br /> 2. To be completed byCOMMISSARYCOMMISSARY OWNER/OPERATOR <br /> Commissary Name A(t�Du C f}2,/t016 Il,W Gk 0,6005 R FA= <br /> Address V717 S. ti/Ji O 0 -S'T Bus. Phone(z 4)1) A 4? <br /> City s Gk'(DA1, e-I Zip gs,20 (, Owner/Operator /19T— T1 iq_a 0 <br /> Check all appropriate services provided: / <br /> [�VVastewater disposal 6-compartment sink M Electrical hook-ups <br /> `Solid waste disposal [Food preparation /Toilet and handwashing <br /> 1:76Hot & Cold water for cleaning I�Store refrigerated food �i Potable water <br /> &-Store dry food/supplies J &Overnight parking Vehicle wash <br /> I,f}"��KFYj)C) - imJ&-)t 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 own hal iafy-th'a1,_ <br /> at erJi to el <br /> Signature �Z Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> .tori, _..,I .ii'l'.. v T _02' -34 F 200--1 J. j'_:1-1 <br /> Zq�"LIP <br />