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')(41(0 <br />Evronmenta Heetien Lic; rtynerli <br />olid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />commissary otify the EHD immediately. <br />Signatur Date /z-//--?j <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 />To be compl ted by APPLICANT <br />j <br />Business Name <br />Owner/Operator Name s 4 -x <br />Business Mailing Address 6) ,4. r7v,e,4-,...,/ 5/ <br />City e3Z4A52 Statee4 Zipl-Z/2.- Bus. Ph. Z.e). 661- .7-.175-Alt. Ph. /0 •--/j"-- <br />I, <br /> <br />('iy J ./ ix( e , 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 penalties. _ _ <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 6/14-1/ 123 Z) FA# <br />Address 7 -Z-O . )),*-0 r -cc— Bus. Phone 709 /7x 7zvi? <br />City <br /> <br /> Zip 5 ?.O 7._Owner/Operator 7, <br />Check all appropriate services provided: <br />Lic. Plate # 4_S <br />Date A <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />Electrical hook-ups <br />Toilet and handwashing <br />Vehicle wash <br />, 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 m ith the conditions of this agreement, or if this agreement is modified or cancelled, the <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin 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