Laserfiche WebLink
� s <br /> SAN !0 A Q U I N Environmental Health Department <br /> U1 kL- __.-__COUNTY------ <br /> { Greatness grows here RECEIVED <br /> COMMISSARY AGREEMENT JAN 21 2020 <br /> Mobile Food Facility * Caterer <br /> ENVIRONMENTAL HEALTH <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County alsd1RFf6ff*VW00E% <br /> 1. To be completed by APPLICANT <br /> Business Name Lie. Plate# gf9�dZ I <br /> Owner/Operator Name <br /> Business Mailing Address l-Z3Y <br /> City StateC�6_ZipBus. Ph. Alt. Ph. <br /> I, 0 aa:2—, 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 p it hold must notify the EHD. Failure to notify this office may result in permit <br /> revocation and nalties. n <br /> Signature720 <br /> Date -202-0 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> J <br /> Commissary Name Ct., U`J FA# <br /> Address 2 L . &4UBus. Phone Abd - yLp q <br /> City Zip Owner/Operator , ,��i' ��ai'llf <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink Electrical hook-ups <br /> Solid waste disposal D Food preparation 36 Toilet and handwashing <br /> $ Hot& Cold water for cleaning [3 Store refrigerated food I9 Potable water <br /> I re dry food/supplies t Overnight parking td Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge nd meets the California Health&Safety Code requirements. If the food facility <br /> operator failmply with th onditions of this agreement„ or if this agreement is modified or cancelled, the <br /> commissa own shajl notify EHD immed�i�tely. L <br /> Signature -�7Ly1�c9 G �f �:'�Lt.�` 7� ' Date / 20 -x/20 <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 /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />