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_ X12 <br /> S A N )0 A QU I N Environmental Health Departme <br /> -- <br /> COUNTY- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a 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 v40VIUL' kjC`jt- 1�)l LLC, Lic. Plate# C <br /> Owner/Operator Name vA L L ' PQL t L L <br /> Business Mailing Address 2--O �c C- li5-1 11 5 <br /> City�� l��(C"fU �� State Q'3, � Bus. Ph. `�)j 0 ;It. Ph.-2 7 fr;L�� <br /> I, 0 t- CJ� Ali,E N �A L OAA i-(;6ereby 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 th <br /> commissary is discontinued, the permit holder must notify he EHD. Failure to notify this office may result in permit <br /> revocation and penal/s. b Signature �` �_ Date <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> CommissaryName UA;tG:l: C.A IC6A,0 -T1QCi<- Ccr,,1(-k:-FA# <br /> Address Llfurt c S� Bus. Phone L�' ��- <br /> City �a(;(Jc I C%V Zip CI ,ZG L, Owner/Operator <br /> Check all appropriate services provided: <br /> tt Wastewater disposal D 3-compartment sink 0 Electrical hook-ups <br /> pg Solid waste disposal 0 Food preparation 2t Toilet and handwashing <br /> Iff Hot& Cold water for cleaning 0 Store refrigerated food 5 Potable water <br /> ❑ Store dry food/supplies 0 Overnight parking [% Vehicle wash <br /> I, (�,�� , hereby state that the information I have provided is current, true an <br /> correc to the best of my knowledge,and meets the California Health& Safety Code requirements. If the food facility <br /> operator faits to comply with the oo ditions of this agreement, or if this agreement is modrfied or cancelled, the <br /> commissary owner steal notify tr HD immediately. <br /> - ISigna`a <br /> 0 <br /> . T W#!f--ENVISE . Tt-t�urc dict oR-qutslde of San Joaqu o� <br /> The i" 'a bzmd ir, — --County. The above fond facility meets the <br /> CAND-us Hiteeft 6 Sem Cj.. It* al(yve eked services are available at the <br /> c',,;,e a perrrA dwVes. <br /> s 3tti -xitr:�s l; S tmNa .. ja 5627-IS`1 Y 3M.} F 2M x,54-013;n l ww*.&j90v orgle <br /> �2 ? � , �; C��tea_-; _�.� �� � -�._�-, �► ��. <br />