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SANtJ0AgU1N Environmental Health Department <br /> I-' <br /> —COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility♦ 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 Lic.Plate# L 0-z– <br /> Owner/Operator Name Nu�cthq C G� <br /> Business Mmall�inq Address ef©ci <br /> city S G 1 Stat CAZip�_Bus. Ph.;Y)l ��� 1t. Ph.e?�� -5 )%21I� <br /> I,Ar(¢I ,"i k el e f}C 1 n,hereby state that the above information is current,true and correct to <br /> the best of my knowledge and haree 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 ho er must notify the EHD. Failure to notify this office may result in permit <br /> revocation nd penalties. t� <br /> Signature o L Date I g z z <br /> 2. To b B completed by W <br /> MMISS. O NER/,P, -RATOR,.: ; , <br /> Commissary Name � FA# <br /> Address Ol/ Bus. Phone P1 <br /> City Zip Owner/Operator <br /> Check all appropriate services provided: <br /> M Wastewater disposal 6 3-compartment sink $3 Electrical hook-ups <br /> dj Solid waste disposal Q Food preparation b Toilet and handwashing <br /> `0 Hot& Cold water for cleaning p Store refrigerated food 1§ Potable water <br /> E3 7e dry foocl&upplies ] Overnight parking r Vehicle wash <br /> I, v Af l i hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, Bets e California Health&Safety Code requirements. If the food facility <br /> operator fails comply with the itions of ththis agreement, or if this agreement is modified or cancelled, the <br /> commissa v r shat notify t EHD immediately. <br /> Signature -- Date t '/� <br /> 3. To be cam leted by,the ENV HEAL 'u,risdic:ion 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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br /> a <br />