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Environmental Health Department <br />COU NTY— <br />Greatness yrows here. <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 completed by APPLICANT <br />Business Name 1. Ot_ A L /05 Lic. Plate # 2-- a_ 6 39 <br />Owner/Operator Name 1_ a ov.A, Q u e.Lti SI, — <br />Business Mailing Address S- z- (v\ 0 0 y t) L41(4 1 <br />o <br />City 5cArivv‘zo I State c et Zip cfc ,r2113us. Ph.9 (•/ 5 ‘5- Alt. Ph. q/ &9 <br />I, L4, r` ) 'VV.( au,L-1,419. , 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 />/ Date <br />Commissary Name <br />Address .-z_Cl; <br />City zip •-75 <br />FA# <br />Bus. Phone (207) E :5 5 <br />Owner/ Operator 1*-14Jr0 <br />Check all appropriate services provided: 01\1 ric• Wastewater disposal <br />12( Solid waste disposal <br />ik Hot & Cold water for cleaning <br />, <br />AllaYStore dry food/supplies <br />-compartment sink <br />0 Food preparation <br />0 Store refrigerated food <br />aNOvernight parking <br />k Electrical hook-ups <br />Toilet and handwashing <br />1A.Potable water <br />4Vehicle wash <br />?.1--ec-c— , 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 owner shall notify the EHD immediately. <br />Signature <br />45/ ZS/ Date <br /> <br />1 3. 'TO be cOMPleted by the ENVHEALTH jurididtibh but:Oide.sofSn JOaquin Co. I <br />The commissary is located in County. The above food facility meets the 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 <br />Date <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd