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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile F009 Facility • Caterer <br />CA -inc.-Jr sectors / and 2 If your xirwrissary rs fixated outsrde of San .&aaquir, County ao corrOele wcbor 3 <br />1 To be completed by APPLICANT <br />CONFf,TE Lt< Plate* 24 V LIV Bustness Name <br />Dwrer.Operalor Name N A CPc PI 0 <br />BusineaS Mailing Address Lj 15 N Nt,tiTui2-P\ <br />coy MTN ti DV fstateZip 15311 Bus Ph ;t0.: dirt utgrAti Ph <br />CkiON INt Nsretry State that Me at)own trfrirmatuln rs curre."1 tr 5r4 to <br />!+le best of my knowledge andagree to utilize my approved commissary rn moon:larva) *In eanforn,a Hear 8 <br />SAW, Curie vi San Joseun County invironmental Health Departmert iEHD; reqt;•reme-Is lt the use c' the <br />wrrornesaryc discontinues: the permit holder mast notrN etc [HD Faure to rot. fy Ms office mail rm.!!r.CrviTni! <br />revocation and penalties <br />Signal Ire <br />2 To be completed byS.OMMISSARY OWNER/OPERATOR <br />Commissary Name UNION (jaVANiti WyCjciNta ( Mrst•ts. <br />Address fl VL V N Oh_ 61- Bus Phore • 1-1 - Li I tO <br />city -.11,11)(f-11) N zIp 1614 kji Owlet/Operator _2,1 TIR—PcM) <br />Check al: approDnotr services provided " Pc ti N <br />X Wastewater disposal 0 3<empartrnent VAC 0 Electrical hook-i-Ds <br />iN Solid waste disposal 0 Food preparation 0 To let and hanctwashg <br />Hot & Cold water for cleanung 0 Store refrigerated food 0 Potable water <br />0 Stsa izt fiVi sopplies 0 Overnvrght parking LI Vehiele wash <br />t 14 (1J IL ie-eN 11F-PcDO nerecli stria that the r forrrabor. I have provvoed is carer, tr,e and <br />corrtt to to best of my knowledge and meets the California Health & Safely Code requiremenis It the toed racii 4 <br />operator fa is to =TV' v :or tne coreircns of this agreement or ,t thti agreement -s rnoclitod or rancyalliel tr* <br />t:omr. asar new Eihali nct ,o., rito:-fir mewl, <br />Stgneture 1... fif A.61 ' . 6 Date LS la t \ aut <br />3 To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary Is located County The above food facility meets the <br />commissary fec,orentents r Caztomia Health & Safety Code The above checked voices are available at the <br />aerx.-0 i^x},henissz.y P%moti, Nvtity Fl-ID 0 the *Intl is of Itarr nOrriltinG rArTi!rJ*41.1112C-9 <br />la ItS Sig-year Date <br />186efo -.ratelltyr, Avenue I Stock/Jon, California 062081 T 200 480-3420 I F 299 464-018e I awe/ *Nov avow <br />Lle I 2.1 11,61.4 <br />onn