Laserfiche WebLink
SAN J O A Q U I N Environmental (Health Department <br /> ---- <br /> C0 U f l TY—- - <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections I 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 EI C?12121A-N) -IS 2-�Zq 3>2 Lic. Plate# -.:I- S i -8-2— <br /> Owner/Operator Name S{ir—�f(1°." <br /> Business Mailing Address (D0115 cl S Z pb"Aj t+ G. v <br /> city NIM e State zip �S23 1 Bus. Ph. Mq 2-75 2jiSAIt. Ph.M -20 S 'ZI ZS <br /> I, Sexc'1 D aM,1 ✓G J 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 Coun Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the per .i holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. 1 <br /> Signature C, Date <br /> 2. To be completed by COMMISSARY <br /> (I OWNER7OPERATOR <br /> Commissary Name ( � I ) �rntC, �tc. 1'Pw ij SAJWI�j FA# <br /> Address Z,V yU S .fitrpar � "bb Bus. Phone <br /> City S }u( V-h-n Zip _ ZUI. Owner/Operator drS Q Jb <br /> Check all appropriate services provided: <br /> 1122//Vastewater disposal Qla�compartment sink 13'Electrical hook-ups <br /> U/Solid waste disposal [7 Food preparation ffToilet and handwashing <br /> ,.A Hot & Cold water for cleaning /Store refrigerated food Potable water <br /> t� Store dry food/supplies E-71/Overnight parking rX/ehicle wash <br /> ICU�J v 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 Date I �� <br /> 3. To be com feted b the ENV HEALTH ia6Shcicti6'h, tside of .Sah Jo.a 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 /> 868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0'138 1 vAAv.sjgov.ora/ehd <br />