Laserfiche WebLink
SAN f Q A Q U I N 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 /> 1. To be completed by APPLICANT <br /> Business Name _'Mcps LL &()Q 1 I\_Q Lic. Plate# `"t (0 ClG1 <br /> Owner/Operator Name M M\0 kE P-L A UDA �A A 1�CLS-LAC k <br /> Business Mailing Address �S n 06 Lu)P.(_) ST <br /> CitySly�'[t`d� StateCl'�)f Zip q3'2LtD Bus. Ph.20j)(03-12bG Alt. Ph. <br /> I, AALIA E, MA(ZCLiQ- )__AIfA , 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 aZdena <br /> lties, l� ,'A, <br /> Signature ayrk 6L r 5 Date oul I 2—S,12DZ-3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name QYAu ' ) CI '(CfilvC-► 11: <br />