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SAN dOAQUIN Environmental Health Department <br /> COUNTY-- -- <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 bei completed b APPLICANT <br /> Business Name Q O� 10111 /e Lic- Plate# y V n 2(37a <br /> Owner/Operator Name$Vj N <br /> Business Mailing Address q6 Pitlg226 �r <br /> City '�+Oclooi l Statei�LZip Z I Z Bus. Ph. 20l —RS&—U127 Alt. Ph. <br /> Ke y''1 'v Ihereby stale 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 discontinued,the permit holder must notify-the EHD. Failure to notify this office may result in permit <br /> revocation andel p/realties. 7 <br /> Signature %� Date <br /> 2. Tobe corripl2tR!j.by COMMISSARY`OWNEWOPERATOR A <br /> Commissary Name �, — FA#_OD 49.3 <br /> Address ' (p 2 od M4.,- to rel Bus. Phone .ZOg - 7d9 -TsP q�a <br /> City W b-,o,( Zip__y-5_37F;0 Owner/Operator vV <br /> Check all appropriate services provided: <br /> Wastewater disposal O 3-compartment sink Electrical hook-ups <br /> Solid waste disposal O Food preparation I0Toilet and handwashing <br /> Hot&Cold water for cleaning 13 Store refrigerated food I(PPotable water <br /> O Store <br /> dry food/supplies Overnight parking p"Vehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledgefand 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 /> Ea' <br /> all no a EHD immediately. <br /> Date 2 <br /> ted b .the ENVrHEALTH jurisdiction outside ofSan'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 /> „. .10 SN 83 ID <br />