Laserfiche WebLink
SAN J 0 A Q U I N Environmental health Department <br /> COUNTY— <br /> COMMISSARY <br /> OuNiY---COMMISSARY AGREEMENT <br /> Mobile Food Facility 0 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 /> Business Name Lic. Plate# <br /> Owner/Operator Name i <br /> Business Mailing Address <br /> City State 6*-Zip 5 �0-5- Bus. Ph. --X k 2Alt. Ph. <br /> I, ;,/a%,/� ���r✓a/2, ;r 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, th rmit holder must notify the EHD_ Failure to notify this office may result in permit <br /> revocation and penalti . <br /> ` 31,1 <br /> Signature Date <br /> 2. To be completed b COMMISSAR OWNER/OPERATOR WM <br /> Commissary Name La= <br /> L FA# <br /> Address Bus. Phone)) '7Z) <br /> City � 7� � , ZipGI' ��U �l Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink Electrical hook-ups <br /> Solid waste disposal - Food preparation _=z Toilet and handwashing <br /> ji Hot& Cold water for cleaning Store refrigerated food �t Potable water <br /> w S e dry food/supplies Overnight parking 7 1 Vehicle wash <br /> -Z- , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and bets the California Health&Safety Code requirements. if the food facility <br /> operator fails to comply with the co ions of this agreempnt, or if this agreement is modified or cancelled, the <br /> commissary n r shall notify the mediately. <br /> n �rt� tit Date Ja <br /> Signature <br /> 3. To be completed by the ENV HEALTH H urisdiction outside or Sari 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 e 209 468-34201 7- 209 464-0138 1 wvrw.sjgov.org1ehci <br />