Laserfiche WebLink
SAN J O A Q U I N Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 9 and 2. if your co nmissai}l is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed by APPLICANT <br /> Business Name y Lic. Plate 7-if 7 <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City - t-rQ�✓ Stater4 Zip Bus. Ph. 2� It4h. <br /> I. 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 permith er must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penaltjg�— <br /> '_'_ <br /> Signature Date /1-7-— % <br /> 2. To be completed by COMMISSARY <br /> COMMISSARYOWNER/OPERATOR <br /> Commissary Nameo A Jpe—JN � w"& Zy� lyy <br /> Address <br /> �S• i S • Bus. Phone 4 <br /> City Zip Owner/Operator ti Pnl'C�5 <br /> Check all appropriate services provided: <br /> E5�/VVastewater disposal 2-7'3-compartment sink Electrical hook-ups <br /> olid waste disposal LEI Food preparation Qoilet and handwashing <br /> 1 l t & Cold water for cleaning 01--S---tore refrigerated food potable water <br /> G1/Store dry fc d/suppli Overnight parking ✓Vehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the beFf my kn vledge, nd 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 /> commissarvImtvner Q11 notii the E immediate) . <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin 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 /> -:65 E. Ha=eltc; ..'-(i L, I Slc_i,l',.i 1. ._�I*irJ fnl T _..J 4vn 3-120 F 209JE5 <br />