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SANS- JUANIN Environmental Health Department <br /> —COUNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Faottity,� Caterer <br /> Compleie sections 1 and 2. f;your commissary is located outside of San Joaquin County also complete section 3. .. <br /> L Ta be:e�m ` ated:E APPLICANT.: <br /> Business Name An M's r 0 Lic.Plate#_ 9?j Ll <br /> Owner/Operator Name e 0 r!cie <br /> Business Mailing Address 3 r C4 th SEI t01 1z . <br /> Cl4r 5jQd6 0 . State&Zip CU Bus. ?h. tit. Ph.r7401) 116 a-300 <br /> 1_ hereby stale that the above information is current true and correct to <br /> the bee r my krimiledge and agree to uhiize my approved commissary in accordance with California HeaiLN <br /> Safebf Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,th p>rmit er must notify the EHD_ Failure to notify this office may result in permit <br /> revocation , penalties. <br /> Signature Dat <br /> �be Com leted.by COMMISSARY O1CVNERI9PERKI—OR <br /> Commissary Name L A Cra,nnz-�c A ' FA# <br /> Address UIOD '—: 4,,f(vrA;.ma Vta-; Bus. Phone X2031 Z4 16�14 ' ,V 5 10 <br /> City `^'s E) t!! Gip : s '7A ownerloperator CL—,�p) Wil. �rryr'4� •.t <br /> Checit all appropriate services provided: <br /> ze e Ells -' 'Gat hook-ups <br /> ;:,r Vttastewater disposal � �, compartment ink <br /> olid waste disposal Food preparation T ?let and handwashing <br /> 0 VAklot&Cold water for cleaning M Store ref igerated food Potable water <br /> Store dry fo dlsuppii i/overnight parking Em Vehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the beat of my i ovalsdge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator-ails to comply 'ih the conditions of this agreF�ment, or if this agreement is modified or cancelled, time <br /> commissary ovrner shall rfy the EHD it ately. <br /> ®- og 2�l a�2 0 <br /> ignatura Date <br /> be ? ated by s ENV HEALTH H on,ou%ide of.Sart:Jo—a uin C�•. <br /> The commissary is looeted in County_ The above food facility meets the <br /> commissary requirements in California Health &Safety Code. The above checked services are avallable at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> RENS Signature Date <br /> 1865 E. Hazei6rsn f-tverLa j ioc;;wr;Califibnar8 9E .OF 1 7 _0g 46R-334201t'= 209 4,6'3-013 I NRtW_Sf(]t1Yr_3re3ieh <br />