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-SKJOAQU,N Environmental lioaith Depaliftent <br /> C+®fi MISSARY AGREEMENT <br /> Mobese Food Fac"Ry dF Caterer <br /> Complete sections 9 and 2, if your commissary is located outside of San Joaquin County also con aplets section 3. <br /> 11. o ba eoMp16ted-t y APPLICANT <br /> Business blame Lie.Plated <br /> Owner/Operator Name Crl prcA rel Vler n 1 g <br /> Business Mailing Address *i-7G l CU r rt4 U 0-0FTt Wagj <br /> Cir< -i(yiwn SWGILZi,a 5Bus. Ph. AIL Ph, <br /> L .hsraby slate that r ee above information is current,jrus and co,mset to <br /> - <br /> the best Of ring/ luiumedge and 2'grusa to utilize my approved commissary in accordantv Aih California Health c. <br /> Safety Code, and San Joaquin County Enuirenmental Health Deparb-nent (EHD) requirements. If the use of the <br /> commissary is discontinued,ilia permit holder must notify teas EMD. Failure to noilfy this oi5os may result in psrnait <br /> revocation and penalties. ' <br /> Signature <br /> 2. Td be cor hploted by COMMISSARY OWNERJOPERATIZIR <br /> Commissary Warne L A Camnes( < to - FA# <br /> Address r.a(JC) [ `Art rkAfi ua% Bzs. Phone i r,f (1 Lj - �>+5 ?() <br /> Q <br /> C <br /> G,L 1 Gam— <br /> idlllf �l (] 'CGV�— <br /> Chack all appropriate services provided <br /> Wastewater disposal M 3-cora} anment sink VIE hook; ups <br /> solid waste disposal 0 Food preparation Toll and hardar/ashirrg <br /> (r Fiat u Cold water for cleaning U trio a refrigerated-food t�able water <br /> Q !Store dry to`adisuppiies t�vernighi parking Vehicle wash <br /> 1, c iec,—�q ;, B Qa wn`r , hereby state that the information I have provided is current, 'true and <br /> correct to the bests my kno pledge,and masts the California Health ca Safety Code requirements. if the food facility - <br /> operator fails to comply with the conditions of this agreement; or if-this agt-semen:Is modified or cancelled, the <br /> commissary owner hail no r-y ` -,b irnmAstely- pp t� <br /> Signature • Date—Deo) 0 r � U <br /> 5, Td WrAmWted by the ENV HEALTH `ul•iadiction outiid®of Saa'jbaouirl 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 /> RENS Signature Date <br /> 1868 E. HzKcaiton Avenue 1 Slocidc,n,CaCr omia 952051 T 009 46-3-34201 F 209-464-0138 j ehd <br />