Laserfiche WebLink
SAN , OA Q U I N Environmental Health Department <br /> ----C O U N T Y— <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�b/y APPLICANT J /} <br /> Business Name d'" 1 G"�GCS a S �;l fZ t"� � Lic. Plate r,= `Gl A <br /> Owner/Operator Name Ae j�e Vokic, <br /> Business Mailing Address <br /> City ee �� State Zip Bus. Ph. Alt. Ph. <br /> I, C11 <br /> C 1 l N0,VC,C, , 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 pe Iti s._ <br /> Signatures Date <br /> 2. To be completed bCOMMISSARY OWNER/OPERATOR <br /> Commissary Name (?e.I j P0/1 n zaL raj ✓, •0)!j FA# <br /> Address 2,-Se Y() S_ 04:11 r, .f lr✓ -9 Bus. Phone �12-0 V1 _ r % / 6 <br /> City Zip C't SZ a4 Owner/Operator 7..u�sy <br /> Check all appropriate services provided: <br /> Wastewater disposal 12'-3-compartment sink electrical hook-ups <br /> Solid waste disposal , Food preparation ? /Toilet and handwashing <br /> Hot & Cold water for cleaning t Store refrigerated food T. Potable water <br /> Store dry food/supplies dovernight parking $Vehicle wash <br /> 1, Z��S \ 1 �r, 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 �✓�� �Z® <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 vAvw.sjgov.org/ehd <br />