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'AN JOAQUIN Environmental Health Department <br /> ± 4 <br /> ---COUNTY ---- <br /> Greatness <br /> --COUNTY ._. --Greatness grows her, <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 Oozey B's LLC Lic. Plate# 4 V K 8 0 9 3 <br /> Owner/Operator Name Lisa Weaver <br /> Business Mailing Address 2108 N Street, Suite 8658 <br /> City Sacramento State CA Zip 95816 Bus. Ph. 209-204-5669 Alt. Ph. 209-207-4222 <br /> Lisa Weaver 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,,ilhe permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date o Ian � am <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Kl1 01 AJ ►c i G-i il�(Ii K C1-tVI c,QFA# <br /> Address )--I )1 .;J %o,%J Bus. Phone 21,C1 - 2`-1 L4 <br /> City ^[S1G( 7(I A_) Zip c.)(n Owner/Operator ? 7)); A <br /> Check all appropriate services provided: OAJ <br /> Wastewater disposal 13 3-compartment sink s. Electrical hook-ups <br /> Solid waste disposal QI Food preparation V Toilet and handwashing <br /> Hot & Cold water for cleaning D Store refrigerated food Potable water <br /> Store dry food/supplies n (3 Overnight parking Vehicle wash <br /> 1414 r) 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 comply With the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o ne sh I otify the EHD immediately. i <br /> Signature Date 12, 2 D,)- <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 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 454-0138 1 www.sjgov.org/ehd <br />