Laserfiche WebLink
SA N vJ OA Q U I N Environmental Health Department <br /> COUNTY <br /> Greatness 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 /> 1. To be compjeted by APPLICANT <br /> Business Name Tum IG__7-0 crar Q"ects& Lic. Plate# <br /> Owner/Operator Name pre' }- <br /> Business Mailing Address lt�< ? �ranQ�, Dtilty C <br /> City Tr�cY State CA+ Zip7S�Bus. Ph. ZO'? T7 1Z:E__Alt. Ph. <br /> I, � ,Q�6r�� fi , 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 ppenalties. <br /> Signature // Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> CommissaryName FA# <br /> Address S� Bus. Phone <br /> City Zip aS3Owner/Operator s,ex-- 4. 'v,,- <br /> Check all appr riate services provided: <br /> p Wastewater disposal 013-compartment sink 13 Electrical hook-ups <br /> 0 Solid waste disposal O'Fcod preparation ;IPl-0table <br /> ' olet and handwashing <br /> 0Hot & Cold water for cleaning a'Store refrigerated food water <br /> St�o�reedry food/supplies 0 Overnight parking 0 Vehicle wash <br /> I, //114 r��„_S j�i1.H , 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 sh I1 notify HD ' medi <br /> Signature Date r 7 S U <br /> q To be com leted 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 www.sjgov.org/ehd <br />