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P(�ko5'i--►b3 <br />fl- Pg- u v z —I I Z I <br />SAN .JOAOUIN Environmental Health Department <br />COUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />Complete sections 1 and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />0 <br />Business Name Lic. Plate # !tu L -5j 39 <br />.. n_ <br />Owner/Operator <br />Business Mailing <br />Ph. ,)C)q-qF'o1"942?AIt. Ph. <br />1 , hereby state that the above information is current, true and correct to <br />the best of my knowled 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 and penalties. <br />2. To be complete#.by COMMISSARY OWNER/OPERATOR <br />Commissary Name- L <br />Address ' b ,Z Q.1 flog0-FIA rel j?'d Bus. Phone X09 - <br />cityLAjjhc,,fLzipA -I>- 0Owner/Operator %.2V <br />Check all appropriate services provided: <br />R( Wastewater disposal Cl 3 -compartment sink t.8 Electrical hook-ups <br />Ild Solid waste disposal E3 Food preparation Toilet and handwashing <br />0 Hot & Cold water for cleaning 13 Store refrigerated food [Potable water <br />13 Store <br />dry food/supplies B"/Overnight parking 13 Vehicle wash <br />I, Sq G V jg «'yf _, 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 shall nojifQtre EHD immediately. <br />1 3. To bVcompleted bV the ENV HEALTH iurisdiction outside of San JoanuinCn_ <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 />