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r <br /> SAN JOAOUIN 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 /> tujdPbe =A <br /> MW <br /> Business Name TA( ()-,' f�ls<�S 10S C�� C` ic. Plate# <br /> Owner/Operator Name J f Ilk,(r'J ('-'o(,2- <br /> Business Mailing Address ;36,)2- :'ff} 6,y1, CA- t,_,,y <br /> City,til�tlO%T� State(,+ Zip Cq_Q) V Bus. Ph.; 1 ' 0 ` -SLS ? Alt. Ph. <br /> I, 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 and enalties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Namecol'[Lxl��_ f.). ( 2��� FA# <br /> Addresses%W ((��,Q, 7 Bus. Phon� <br /> City��\' Zip -kC Owner/Operato 1L 1u - V,� lC� <br /> Check all appropriate services provided: <br /> 16 Wastewater disposal �i 3-compartment sink "2f,Electrical hook-ups <br /> Zj Solid waste disposal ood preparation 6 Toilet and handwashing <br /> �2 Hot & Cold water for cleaning ;ff Store refrigerated food J9 Potable water <br /> ;S Store dry food/supplies j; Overnight parking Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to they 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 owner sha rptify the EHD immediately. <br /> Signatur �Z� Date 1� <br /> 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 Signature Date <br /> "868 E. Hazeitcr Averue S-.cckton. California 95205 T 468-3420 F 209 464-0138 <br />