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th lititside of Sarrioa uin Co. <br /> <br />SAN JOAQUIN <br /> <br />Environmental Health pePartment <br />-r <br />COMMISSARY FoF ac AGREEMENT <br />lity • Caterer <br />i <br />ccwnPlete sections 1 end 2. If your commiSselY k)ca(ed eutlide of San <br /> <br />Joaquin County also compible seam 3 <br />Mobile Food <br />— 1 . To be completed by APPLICANT <br />Business Name <br />_ <br />RO 444:zz2 _Lic. Plate if. 4(M <br />°Ivrie r/Obe ra tor Name J..) Cy' 7 ',— <br />Business Mag Address 1)-0 <br />City CA Sta to CR Zip Biss. Ph. q I &-8t; L- L139 3Alt. Ph qlio - t, -- S 2 <br />herebY stste 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 wah Calrfornla Healm & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is dscontinued, the permit holde, must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature --->-)_Ctis.ki v-c V \C Date //- (-3 - <br />2. To be completed by COMMISSARY OWNER(OPERATOR <br />Commissary Name 41,1 /4771 ,- <br />Address irsi owi tar rte Bus. Phone ‘90 9 _; <br />city .2y_ zip Cc)* OvmedOperator /1/1.-P7/14) <br />Check all appropriate services provided: <br />pi Wastewater disposal 0 3-compartment sink rt( Electrical hook-ups <br />it Solid waste diSPOSei 0 Food preparation Toilet and handwashing <br />Hot & Cold water for cleaning 0 Store refrigerated food pe Potable water <br />Cl Store dry food/Vppliss le Overnight parking )2( Vehicle wash <br />1. "Itiefa it ger , hereby state that the Infortnation I have provided is current, true and <br />correct to the best of my knowIige. and meets the California Health &Safety Code requirement3. If the food facility <br />operator fails to comply vAth the condibons of this agreetrwint or It ego agreement is modified or cancelled. the <br />commissary owner <br />Signature Dote <br />[To be co <br />The commissary is located in County The above food facility meets the <br />commissary requirements In California Floalfh & Safety Code. The above checked services are evadable at the above commissary. MOW notify EHD if the status of their operalkig peamit chartgee <br />RENS Signature Dote <br />1868 E. Hazelton Avenue I ornia 962051 T 209 4684420I F 209 464-0138 www.sjgov.orgfehd <br />TV0S4 8015