Laserfiche WebLink
S A NA Q Q U I N Environmental Health Department <br /> Greatness grows here, <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 /> Business Name �✓ Lic. Plate# <br /> Owner/Operator Name <br /> Business M fling Address % L <br /> S A <br /> City �. States Zip y Bus. Ph.5-AQ ' � � � Alt. Ph. <br /> �a (jp01 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, tl}eermit 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 comple ed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address e� Bus. Phone <br /> City s Zip ?S dQ�_ Owner/Operator__ oc /r Da <br /> Check all appropriate services provided: <br /> Wastewater disposal 13, 3-compartment sink W Electrical hook-ups <br /> F4 Solid waste disposal U Food preparation 19 Toilet and handwashing <br /> 19 Hot & Cold water for cleaning Store refrigerated food M Potable water <br /> Oge dryfood/s plies Overnight parking R Vehicle wash <br /> I, t �L�fz hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge,9nd meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the c itions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ier shall notify th D immediat <br /> Signature "7t t�cX Y 1 Date a i <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 /> pfZo �� 523(,0 <br />