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S A N- J O AQ U I N Environmental Health Department <br />COUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br />1. IV uc VVI11 IGIriY V - v-- ' 1' _ <br />Business Name <br />� n 0v 111 Lic.Plate# "l V <br />6a <br />Owner/Operator Name , t <br />Business Mailing Address <br />City C State Zip Bus. Ph.(76j) 7C <br />a bove in <br />n . <br />�� { L UI til ti , hereby state that the aformation is current, true and correct to <br />1.thebestofedgend agree to utilize my approved <br />st 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 />Commissary Name_ L FA# V % `�— <br />AAA- 1 (n 1) n.l )9.a,-- ✓a rel RA_ Bus. Phone e20c) -.71 -1 — �A"e M <br />CityWVk-n_�Zip 7� Owner/Operator f, V <br />Check all appropriate services provided: <br />i! Wastewater disposal ❑ 3 -compartment sink M Electrical hook-ups <br />E( Solid waste disposal Cl Food preparation 53Toilet and handwashing <br />❑ Hot & Cold water for cleaning ❑ Store refrigerated food 1511"Potable water <br />❑ Store dry food/supplies Overnight parking CSS" Vehicle wash <br />1 A5,- _, 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 // all notifyttie EHD immediately. <br />_ � <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. <br />REHS <br />