Laserfiche WebLink
S A N J O A Q U I N Environmental Health Department <br /> COUNTY <br /> .z <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 S t Lic.Plate 4 8A <br /> Owner/Operator Name ( S <br /> Business Mailing Address 2— <br /> City'�� StateGi Zip Bus. Pl����Z 1 Z_� Alt. Ph a 7J/`�' <br /> - �p/G l' 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 pen tlra;s. <br /> Signature Date <br /> i <br /> 2. To be completed by COMMISSARY OWNEMP/ERATOR <br /> Commissary Name ��t pl�S l dlG�i FA# <br /> Address «J C� �r�t/C��' �� ,dZF- Bus. Phone e " �/ <br /> Ci 7�o Zip Owner/Operator ( t ' <br /> city <br /> Check all appropriate services provided: <br /> disposal Irl�ood <br /> partment sink Electrical hook-ups <br /> Wastewater <br /> ® Solid waste disposal preparation Gff 1 oilet and handwashing <br /> El Hot& Cold water for cleaning 13-8/torerefrigerated food ❑ Potable water <br /> ❑ Store dry foodisupplies ❑ Overnight parking 0 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 caner I n the EHD immediately. uI \ /� <br /> Signature Date_ cy-lJC7.1 <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 mvw.sjgov.org/ehd <br />