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Environmental Health Department <br />Lie. Plate # <br />S-<k<\CV\e^ <br />Date <br />ukAs VrAcvvc<x fa# <br />^Electrical hook-ups <br />Toilet and handwashing <br />&*Potable water <br />VehteU-wash <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />R?2L>0iX3'g <br />SAIWOAOUIN <br />-----COUNTY------ <br />Greatness grows here. <br />—Onctkko Bus. Phone <br />-------ZiP A&To Owner/Operator <br />Date 6- 2^6-’LoXS-_______ <br /> <br /> | 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. j <br />The commissary is located in------------------------------------------------_County. The above food faci|ity meets <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 <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 OHiMfiA I.lG <br />Owner/Operator Name r g Y \ Q s < <br />Business Mailing Address j ~ - /L.-.y <br /> <br />City_^CvuU c ,.G StateCA- Zip 9^ Bus. Ph..Alt. Ph <br />- .‘Y <c,----11 -----------------------------hereby state that the above information is current, true and correct to <br />Safety CoOLmyandnsWan Joaoand e “““ aPPr°Ved COmmissa^ in accordance with California Health & <br />bafety Code, and San Joaquin County Environmental Health Department (EHD) requirements If the use of the <br />revo™nd peXsUed' Pemlit EHD' Fai'Ure t0 thiS °ffice may result in Permit <br />1 ASi9na,ure—Date f -XOZS- <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name X-p <- y <br />Address WQ pj „ <br />City <br />Check all appropriate services provided: <br />g^VVastewater disposal C^B-compartment sink <br />OrSolid waste disposal B^Food preparation <br />>4iot & Cold water for cleaning grgfore refrigerated food <br />©'Store dry food/supplies X OveroightDarkinq <br />k ------------------hereby State that the information I bave 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 />perator 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