Laserfiche WebLink
'� SANA0A0UIN � <br /> `''��� Environmental Health Department <br /> `/' ---C O tJ N T Y—" <br /> `trR;�o�rJ C�rea2n.ss �ro��> ^ere. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 corn teted:,b . APPLICANT <br /> Business Namemem 1 ic. Plate#3Z3SS 93 <br /> Owner/Operator Name I- <br /> Busines Mailing Address 3 _T -kit 1 fSA ,�-� <br /> City t Zip g52Q&us. Ph209 9-/ 2lZ45 . Ph. <br /> ti <br /> I, hereby state that the above information is current,true and correct to <br /> the best of my knowledg a d 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 penalties. 2 <br /> Signature �FV1rL. o Date �J 2 <br /> 2;:T6be_ .om let b ,CgMM1S$ARY.OWNER/QPERATOR„ <br /> Commissary Nam& 11, <br /> 1m" #ol <br /> Address rOl S Bus. Phone <br /> City Zip Owner/01 erato V la <br /> Check all appropriate services provided: <br /> � <br /> ��1/astewater disposal C1,1compartment sink 0 Electrical hook-ups <br /> I Solid waste disposal 0--Food preparation C3 Toilet and handwashing <br /> RF�t & Cold water for cleaning O Store refrigerated food lCN�otable water <br /> ill <br /> e d food suppli s Overnight parking IS Vehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the best of my cnowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to corn ly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> nLcommissa rall thAHD immediately <br /> Signature Date <br /> 3. To be corn .feted Ibthe_ENV.HEALTH jurisdiction outside ofi Sari <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 />