Laserfiche WebLink
SA6J0A0UIIV p <br /> Environmental Health Department <br /> —COUNTY— <br /> Greatness <br /> OUNTYGreatness grows here. RECEIVED <br /> COMMISSARY AGREEMENT FEB 10 2020 <br /> Mobile Food Facility ♦ Caterer ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 ;�J_ 11111a o fro/\_ Lic. Plate# /d�`� <br /> Owner/Operator Name c'i/ CJ G�'r►'�� �i <br /> Business Mailing Address <br /> City State—Z—A-Zip �Zr a Bus. Ph. 9tdlq 4V:7 .3SAlt. Ph. <br /> 1, , 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 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 com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name I <br /> Address Bus. Phone <br /> City Zip Owner/OperatorS <br /> Check all appropriate services provided: <br /> 0-' astewater disposal El--Food <br /> sink Electrical hook-ups <br /> [��lid waste disposal El--Food preparation 13Toilet and handwashing <br /> EL-Kot & Cold water for cleaning 13 Store refrigerated food 13411-otable water <br /> 13 Store dry f od/supplies Overnight parking ehicle wash <br /> 1'� , hereby state that the information I have provided is current, true and <br /> correct to the es of my kn wledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissawn r shall n tify the E immediately. 2 <br /> Signature Date �J �� <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 />