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provided: <br />CJI 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Ea/Overnight parking <br />Check all appropriate services <br />[Tf Wastewater disposal <br />d Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />/Electrical hook-ups <br />ID/Toilet and handwashing <br />"Potable water <br />IIK/ehicle wash <br />SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <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 be completed by APPLICANT <br />Business Name qng <br />Owner/Operator Name et_vi <br />Business Mailing Address q 6 -3 0 Fe4 I clZ20 0 r <br />City (;+00C1vo State6A Zip <br />Lic. Plate # VI) <br />521 Z Bus. Ph. 2(je1 <br /> <br />Alt. Ph. <br /> <br />I, Ke ,Avl A,/ • , hereby state 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 and2n )). alties. <br />Signature/.------- <br />4' ---'-----1----- <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name I, 110-kr-p.12 repo ci ph47,11 FA# 00,279-93 <br />Address I coaal r\J Rd - Bus. Phone ,220/ - itce ?6, <br />City Zip 9$ ;30 Owner/Operator 54-RN 0.- ThrwV. <br />Date H C- ) <br />I, S+401:15.c....1 , 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 own hall no e EHD immediately. <br />Signature Date /12. 7/ 2- ... <br />3. To b completed by the ENV HEALTH jurisdiction outside of San 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.