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SAN J Q A Q U I N Environmental Health Department <br /> COUNT ' ­­ <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s Caterer <br /> Complete sections 9 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 Onyo(,s 16 E CA EA !//���/ <br /> Lic. Plate# 6 <br /> Owner/Operator Name <br /> Business Mailing Address <br /> city C StateCq,Zip9S�CJGBus. P 204 M­A6 It. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the be of my knowledge d 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. � � � 20 <br /> Signature `� (i' �/� Date •C <br /> 2. To be completed by COMMISSARY <br /> gg OWNER/OPERATOR <br /> Commissary Name r I IS U/OYI(,,//CA— I'LFA# <br /> Address IL(30 ;E IW64ER /�V� Bus. Phone L4 <br /> �' X13, 3/ l S � L! <br /> City S Zip p 5 S Owner/Operator L/e_"Q C L('LC rill 1Ue'L <br /> Check all appropriate services provided: <br /> L] Wastewater disposal 3-compartment sink 0 Electrical hook-ups <br /> C7 Solid waste disposal 13 Food preparation WToilet and handwashing <br /> 2-Hot & Cold water for cleaning Er—Store refrigerated food 0 Potable water <br /> .1 $tore dry food/supplies Overnight parking 0 Vehicle wash <br /> I, ZAot C4.6LUMAV-' , 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 immediate) IL/ I <br /> Signature t Date r / <br /> 3. To be completed by the, i1YE'Ailn'�19risdiction 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wvwv.sjgov.org/ehd <br />