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° ; S A N,,J o A Q U I N Environmental Health Department <br /> COUNTY <br /> '.P.ac,= Greatness groves here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility,�% Caterer <br /> Complete sections I 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 OVI Lic.Plate# 20L13 I <br /> Owner/Operator Name LA 61/ 0 7TO <br /> Business Mailing Address ILQL 1 gJt' '\rw it <br /> City!gl%C(C fOM State,C,Zipq�us. Ph.���'Sp-1-�3 ,�-Alt. Ph. <br /> I, /A0/'nIA , 71)reEhereby 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. //-- 7/,;ZpZ3 Signature if �G �r� Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Uy)I UYl C,Ctdt Ylr j 7rucr- 6?/)JPiY' FA# <br /> Address )-11-1 -S UN T(Q Sl Bus. Phone it Ll- 2a 1 <br /> City ip9S,�-_O L- Owner/Operator I' atU- 1 ie.4Vic, <br /> Check all appropriate services provided: W A5 H MW <br /> N Wastewater disposal ® 3-compartment sink ® Electrical hook-ups <br /> M Solid waste disposal D Food preparation RW Toilet and handwashing <br /> Hot& Cold water for cleaning ® Store refrigerated food 5 Potable water <br /> ® Store dry food/su plies K3 Overnight parking i Vehicle wash <br /> I, 11 hereby state that the information I have provided is current,true and <br /> corre 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 owners II noti e EHD immediately. / <br /> Signature Date �!/ ( � -7�aa2.3 <br /> 3. Tobe corn'01e-ted by the ENV.HEALTH jurisdiction.outside.°of,San:Joa >uin 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 /> RENS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />