Laserfiche WebLink
SAWOAQUINp <br />Environmental Health Department <br />—COUNTY— <br />Greotness 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 />11. To be completed by APPLICANT I <br />Business Name <br />Owner/Operator <br />Plate #� 9 3 / s <br />�+-oN S. 6 Ce F- 22 E .e a <br />Business Mailing / 33 % 5. !,-/ / 5 ovn K/Q <br />City s�6>J � State_(�4 Zip � 5 Bus. P . � / 7/f6 Alt. P���9 <br />I, ✓V Yr6", 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 aQd penalties. n <br />Signature Ka>•t� _ 44 � Date 10/13 IAd <br />2. To be completed by COMMISSARY OWNER/OPERATOR. <br />Commissary Name S,5 FA# <br />Address/33� S. l^ /�S�i tray Bus. Phone/% <br />City :5bc'� Zip Owner/Operator K,yfrON S• �iLe�e'� <br />Check all appropriate services provided: <br />Wastewater disposal ❑ 3 -compartment sink Electrical hook-ups <br />Solid waste disposal trFood preparation [Toilet and handwashing <br />11KHot & Cold water for cleaning tore refrigerated food WPotable water <br />QrStore dry food/supplies O -Overnight parking GI Vehicle wash <br />I J'F� 0' ':;: (::� k0 rr?1' , 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/gypmyner shall notify the HD immediately. r7 <br />/moi .'A not. <br />3.36 be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co.- <br />The <br />o. <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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 vAww.sjgov.org/ehd <br />