Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> — <br /> -- COUNTY--- <br /> 9rtr7i• ser:•. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility .t, 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 b APPLICANT <br /> La ck (�t�( <br /> Business Name L c�yCn c—b i A2@Lic. Plate# <br /> Owner/Operator Name I`tet oo Aft <br /> Business Mailing Address r7g2l�7A \ Ci. <br /> City S�tate� Zip�Bus. Ph. O5"3a c�AIt. Ph. <br /> PVC1 VC2— , 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 a1ve . <br /> Signature .64 .�5/'�' t'� Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> jj <br /> Commissary Namei0A )I Cr1 <br /> �' , I' IvLrTp/_TFA# <br /> Address 1r <br /> c/f7 cr)rt wG Bus. Phone ''2 ' Sr( I 04 <br /> J <br /> City S c-?' K h,rn Zip q S-Z_6 wner/Operator <br /> Check all appropriate services provided: <br /> %j Wastewater disposal L( 3-compartment sink T( Electrical hook-ups <br /> Solid waste disposal Food preparation kir Toilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated food K Potable water <br /> Stone dry food/supplies fFA Overnight parking l�rVehicle wash <br /> I, F{2ci � <br /> PL,✓'6:;:" —. 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 /> i3 z <br /> 3. To be com feted 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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />