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t (2- SAN 10 A O U I N Environmental Health Department (L N l COMMISSARY AGREEMENT Mobile Food Facility # Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. 1. To be completed by_APPLICANT Business Name f— U I v G U IF f\L y Lic.Plate# V7 3�_ 0 U 1 Owner!OperatorName I l< N F11 I N A- f Business Mailing Address �Ol'l I ��F F P-O N D P, - City I r=n 7 State Zip 7 J Bus. Ph.-Lt'` 5(01-61LP0Alt. Ph.U',�P, UNihereby state t that the above Information Is current,true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health 8 Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit t revocation and penaltie . Signature_ Date�L Z ' l 2.o be completed by COMMISSARY OWNER/OPERATOR i Commissary Name(JNM IXA, Vn "ro)rk nrf, aI;owl Address Addressi_ 11 UNION 571- Bus. Phone C 2_01)261 City-- :7-41rl.f=-i_A �! P�Zj _ O •-, �y0 _ wner/Operator I I �0 Check all appropriate services provided: VV Px,5R 0 N 01 Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups Solid waste disposal u Food preparation Toilet and handwashing Hot&Cold water for cleaning ❑ Store refrigerated food Potable water ❑ Store dry food/supplies ❑ Overnight parking ,�Vehicle wash I, y Fq V la Q)<_A_ ,hereby state that the information I have provided is current,true and i correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility operator fads to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the commmeary ownor s II no he EHD immediately. r Signature _�_ �y .S/7 - Date � L_y ------------- be completed bythe.ENV HEALTH jurisdiction outside of San Jo-- agwin Co 1 I The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date I 1868 E Hazellon Avenue I n,Californialifornia 95205 1 T 209 468-3420 1 F 20946"138 Stockton, 1 www.$)gov.orgiehd f i i i I