Laserfiche WebLink
SAN J 0 AQ U I N Environmental Health Department <br /> ---COU NT'(--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility .v 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 A S— 9 c F_ CR E f M Lic- Plate# G 00 1 SGY'�k, <br /> Owner/Operator Name A -7 n'I JEg SWC, p <br /> Business Mailing Address-3" /,a L:-', M i f� (�V L <br /> 7 <br /> City S'7o Gk,Ta v✓ State !:._�Zip of S`koS Bus. Ph. Alt. Ph. <br /> I, , 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. (I p <br /> Signature {"�,� _0 ���1„ Date <br /> 12. To be completed by COMMISSARY OVVNER/OPERATOR <br /> Commissary Name P i CY, (TV R o A C L CR C- ft M FA# <br /> Address _!o cr(' %ovt/ c '4 OI S A I S� Bus. Phone `Z�o f-\— <br /> City Zip Owner/Operator —4 CO n <br /> Check all appropriate services provided: 0 N <br /> j Wastewater disposalC! 3-compartment sink �� Electrical hook-ups I rn C) <br /> r_1 Solid waste disposal E'!!. Food preparation ul Toilet and handwashing Z F,O <br /> M Hot & Cold water for-cleaning _Store.refrigerated-food.___. U Potable water _ Z M <br /> 0 Store dry food/supplies � Overnight parking !M Vehicle wash D X 0 <br /> W D X <br /> I, hereby state that the information I have provided is current, true ancc G m <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facilityp rn > <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, theme 9 <br /> commissary owner shall notify the EHD immediately. <br /> Signature Ir„t �. fo Date of— `oI-- 21- <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin.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 1 Stockton, California 952051 T 209 468-34201 F 209 464-0'138 1 �,vv,,v.sjgov.org/ehd <br />