Laserfiche WebLink
tai Depainitman" <br /> - C O U 1\1 T ---- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 9 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 t Lic. Plate# <br /> OwnerlOperator Name <br /> Business Mailing Address r' c � •�� <br /> C�� r`!SZ7 � Z�S Z' SAIt. Pn.Zu "1 �I S 2j �'S <br /> City (,,/i:1%1 ��' State Zip Bus. Ph. <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 CountyEnvironmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,the permif holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties/� <br /> _ �Signature �. ?fes Date �t <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ,� ! �y' Y�«� lac -��a✓� �) p1`l`I FA# <br /> Address qu S AkI-pc r t-`'► Bus. Phone <br /> City -c�� G;� Zip CJL Owner/Operator c_-& <br /> Check all appropriate services provided: <br /> ,LAVastewater disposal iiicompartment sink P Electrical hook-ups <br /> r'Solid waste disposal Food preparation : Toilet and handwashing <br /> _- Hot & Cold water for cleaning Store refrigerated food r otable water <br /> ..Store dry food/supplies %Overnight parking `:�ehicle 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 notify the EHD immediately. <br /> Signature ___ -Date- <br /> 3. <br /> ate3. To be completed by the ENV HEALTH jurisdiction outside of San Jm 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 I Stockton; California 95205 1 T 209 468-3420 1 F 209 464-0138 1 NwAv.sjgov.org/ehd <br />