Laserfiche WebLink
SAN JOAQUIN 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 APPLICANT <br /> Business Name L', ;` +� I ` Lic. Plate <br /> Owner/Operator Name 1 akl) <br /> Business Mailing Address Oq 10 bye u�. <br /> City t( StateCA Zip L3.1(,,Bus. Ph.� - (OMAIL Ph. <br /> 1. nye <br /> ,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 an penalties. <br /> Signature WyLl— Date Sit OauaCU <br /> 2jo be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name J � FA# <br /> Address 3°i �01�,,, Bus. Phone �S g3 I (o33 I <br /> City —i c"% Zip 3O Owner/Operator T—)f., 3 of /`101 M C(211��/ <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge,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 /> commissary owner shall noti e EHD immediately. <br /> Signature Date <br /> 3. To be comleted b 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 /> RENS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sigov.orq/ehd <br />