Laserfiche WebLink
SAN_JQA0UIN Environmental mental Health Department <br /> —COIJN T y.- <br /> �Kr Chea HtNss �7r �•:s . . <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s Caterer <br /> Complete sections 1 and 2. H your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name Uc. Plate# V J f <br /> Owner/Operator Namer <br /> Rusin s Maili Address L l , <br /> City StateZip (�Bus. Pt�flq ��n 6 `I Alt. Ph. <br /> !, , hereby state that the above information is current,true and correct to <br /> th est of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, nd San Joaquin County Environmental Health epartment (EHD) requirements. If the use of the <br /> commissary i discontinued,the perm t hoi ust notiry E Failure to notify this office may result in permit <br /> revocati iti ' <br /> Signature Date -� <br /> Commissary Nam <br /> Address 1r Bus. Phone <br /> Ci rllvo Zip_AS?L3 Owner/Operator }� <br /> Check all appropriate services provided. <br /> {/Wastewater disposal Q'S--compartment sink CI'Electrical hook-ups <br /> E!rSolid waste disposal mod preparation IY1 oilet and handwashing <br /> CrHot& Cold water for cleaning E3 Store refrigerated food E]'�ta le water <br /> C Stc a dry � <br /> f suppii Aernight parking [;'Vehicle wash <br /> L�/r-. (t�•w ��hereby state that the information I have provided is current, true and <br /> correct to the best of my nowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to com ly with the conditions of this agreement. or if this agreement is modif d or cancelled. the <br /> commissary r all n th HD immediately <br /> Signature � Date L Z <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 ! T 209 468-34201 F 209 4640138 1 www.sjgov.or9"ehd <br />