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SAN J O A Q U I N Environmental Health Department <br /> LjNTy <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility f, 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 �b,� APPLICANT <br /> Business Name Lic. Plate k__9 V K9_1 Zy <br /> Owner/Operator Name OVA 0-A-1 <br /> Business Mailing Address—1,4b f%jaroexo �k <br /> City � UW StateGR Zip gS20y Bus. Ph. Alt. Ph. 209 -11% LAI3`"t <br /> I, Ll �}u 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 nalties. <br /> Signature DateF2—. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Uuikrm -TgF,,1# <br /> AddressS, k) Bus. Phone 2VI ' --� _r <br /> City �0 LL-h k) Zip Owner/Operator to 1 ray_ r {,l�Tnt�i o <br /> Check all appropriate services provided: <br /> 70 Wastewater disposal rK 3-compartment sink 0 Electrical hook-utas <br /> Soiid waste disposal- 0 Food preparation 9 Toilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated food is Potable water <br /> D Star dry food/supplies El Overnight parking br",vehicle wash <br /> I, I hereby state that the information have provided is current, true and <br /> correctto the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br /> operator fails to comply wi e i ons of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner s ti e EH immediately. �7 <br /> Signature Date �S <br /> 3. To b leted by the ENV HEALTH jurisdiction outside of San Joa ujn 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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />