Laserfiche WebLink
SAN JOAQUIN <br />-taw, —COUNTY <br />cnaSxor,../ ureatness grows here <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility. Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />Owner/Operator Name <br />12,&rt. LifIlr. <br />Business M <br />City <br />1,/c2WitieiSeD Paik Go m , 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• -rmit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Business Name <br />iling Address /D oi /-1 5 . <br />Sta44 zipq5a/c- Bus. Ph.670 .42-z--9L-Alt. Ph. <br />Lic. Plate # 5 ell <br />Date /4; 9f? Signature <br />2 To be compl ed by COMMISSARY OWNER/OPERATOR <br />Commissary Name a<4 (1.01)ivt&id <br />ta Address e <br />City Zip qs--aoc---- <br />Check all appropriate services provided: <br />FA# <br />Bus. Phone 9 —1 70 <br />Owner/Operator ,e41 A '.04410=,, <br />G9'1's <br />ti Wastewater disposal <br />NI Solid waste disposal <br />fil Hot & Cold water for cleaning <br />e dry food/s plies <br />correct to the best o my knowledge, <br />operator fails to comply with the c <br />commissary er shall notify th (7 <br />signature -0-71-44x-e <br />El 3-compartment sink <br /> Si Electrical hook-ups <br />Food preparation <br /> rir Toilet and handwashing <br />fa Store refrigerated food <br /> El Potable water <br />13 Overnight parking <br /> 113 Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />nd meets the California Health & Safety Code requirements. If the food facility <br />itions of this agreemen or if this agreement is modified or cancelled, the <br />D immediat <br />Date ,;2- — <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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd