Laserfiche WebLink
SAN 1 Q A W N Environmental Health Department <br /> --COUNTY— <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 /> f , <br /> Business Name v' a_ Lic. Plate# �y yso2 <br /> Owner/Operator Name t ` <br /> Business Mailing Address <br /> City State&" Zip 5 S us. Ph J p i`9- `C-3 7� /0 <br /> I,JL4�22& /1d 1W P_" , hereby state that the above information is current,true and correct to <br /> the best of my knowledgeand 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 permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name%l� FA# <br /> Address d JW CC i� Bus. Phone,, 29q- <br /> City <br /> 9c-City c�0L�,cf Zip S- P Owner/Operator AAZ& <br /> Check all appropriate services provided: <br /> It Wastewater disposal 3-compartment sink w Electrical hook-ups <br /> E6 Solid waste disposal 0 Food preparation Toilet and handwashing <br /> Oi Hot& Cold water for cleaning ® Store refrigerated food Potable water <br /> 0 S e dry food/ plies ' . Overnight parking Vehicle wash <br /> I, �� , ,�_ _ hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge,and ee s the California Health&Safety Code requirements. If the food facility <br /> operator fails c mply with the con Ifi s of this agr ement or if this agreement is modified or cancelled, the <br /> commissa ow' shall notify the i mediately. <br /> Signature w, Date _ J aha b <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 952051 °T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />