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SHAWN Environmental Health Department <br /> ciL .i' Greatness,grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility• Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1.To,be.com eted-by APPLICANT:'.' <br /> Business Name d+ , Cf c`t ic.Plate# C C <br /> Owner/Operator Name l u nAc/[,!�-_ j j( <br /> Business Mailing Address q� 7 >/ e 6 W 6 CA 0 S� <br /> City��State_C Zip Bus. Ph.?l9 93 1'7Z) Alt Ph. <br /> hereby state that the above information is current,Aue and conect to <br /> the best of my knowled a 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 pen . <br /> Signatu _ Date 0 o <br /> 2:Tobe completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L A C(,)Mp.,r Cc r FA# <br /> Address �Acy .vse Wcl!! Bus. Phone 0061 • 14 �� ��s 70 <br /> City oyo Lt<.koy\ zip CIS 2o5 Owner/Operator C`nb p A cf)e.A-t <br /> Check all appropriate services provide <br /> _d: <br /> [Wastewater disposal W3-compartment sink cal hook-ups <br /> eSolid waste disposal O Food preparation T -let and handwashing <br /> @ Hot&Cold water for cleaning ©— S/tow refrigerated food able water <br /> ill Store dry food/supplies Ovemight parking Vehicle wash <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 immediateI . <br /> Signature Date 1 - 1 . <br /> 2-0 <br /> 3..T.o:be com l6ted by the•ENV HEALTH 'urisdiction outsidebf-San J.oa ui7n 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 penin changes. <br /> REHS Signature Date <br /> 1868 E.HazeRon Avenue I Stoddon,Cafifomia 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />