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SAN JOAQUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t Caterer <br /> Currlu,here sections 2 a9d2. 11 yrciur currvrussaryis localed owsxle co Sen juawn county also ccmbleie seckon 3 <br /> 1. To be oompleted by APPLICANT <br /> Business Name_W bAKES r Shof1 ND 1R9Y33, 1, Lic.Plate# _ <br /> OwnedOperator Namempky-1RM ��'z' _ <br /> Business Mailing Address_ll.1�132 Cf-FRQt tt- PAdzy. c,%YL." _ <br /> City _S1atl-WZip!iS Bus. Ph.���}Z 319-1- Alt Ph. CZa°I �elh- Q3�� <br /> I, M rVASSb hereby state that the above information is current.true and coned lo <br /> ft best d my knoMedge and agree to ut ze 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 /> comnnssary is see in d, the pemfd troller must notify the EHD- Failure to notify this office may result in permit <br /> revocation a penal s / <br /> Signature Dale M/ 7 f 2D'L1 <br /> 12.To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name 2:n& GaarhT b44&4-LoO-Ajf e FA# <br /> Address 27D 4vA-.Jji IQ V /4-J Bus. Phone <br /> city� zip-10 <br /> 0Y OwnedOperator_j�>_U 1, <br /> Check at appropriate services provided: <br /> Wastewater disposal *3-compartment sink ❑ Electrical hook-ups <br /> (Solid waste disposal Food preparation ❑ Toilet and handwashing <br /> t -Hot &Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> `❑ Store dry foodlsupplies ❑ Overnight parking Ll Vehicle wash <br /> I, 4J S•�`7r /IE 2 ,hereby stale that the information I have provided is current,true and <br /> correct to the beg of myknowledge,and meets the California Health&Safely Corte requirements. If the fmd faddy <br /> operator fads to comply with the conditions of this agreement or if this agreement is modified or cancelled, the <br /> com missaryowner shall natty the EHD immediately. <br /> Sigrhature�� Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary es 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 /> abcve commissary. Please no*EHD d the status of their operating permit changes. <br /> RENS Signature Date <br /> 1868 E. Hazellon Avenuel Stackbn,California 952051 T 209 468-3420 1 F 2179464-0138 1wvvw.sfgcv.org1ehd <br />