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' AN JOAQUIN Environmental Health Department <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 /> 1 . To be completed by APPLICANT <br /> Business Name P/,p kl-i4 Lic. Plate# <br /> Owner/Operator Name ZN %/D /1/)r{0.9 EIZA .7<�' <br /> Business Mailing Address / �r _� 0 7'/4/q <br /> City �� �� State <br /> �Zip�Bus. Ph.. ° �;��/ —671'7 Alt- Ph.-26 j' �gg 25� <br /> 1. 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 discontin , the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe <br /> Signatur Date t19-" '20/ <br /> 2. To be &mpleted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 9TVCK01\11-<4)P-J ici_-0 jy�A# 4!j,�Z �j 77 <br /> Address V Bus. Phone �,,9 06 _ <br /> City � ,� Zip Owner/Operator U�E� fM+.v�,P <br /> Check all appropriate services provided: <br /> p Wastewater disposal TZ��-compartment sink ��'Elec ical hook-ups <br /> E3 Solid waste disposal 0—Food preparation Toilet and handwashing <br /> rX'Hot & Cold water for cleaning 5 Store refrigerated food 121 Potable water <br /> 0--ISI—tore dry food/su plies q E Overnight parking 0 Vehicle wash <br /> 1, V&—eA0 CCUIL4Wet— , 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. " Q <br /> Signature ��l fgd,� tom'v— 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 /> i 68. E. Ha%eitor� N^deme I Sta_k'ton, CaGrornia 205 i T 209 4E8-3=+ F 209 46,4-0138 <br />