Laserfiche WebLink
S A N 1 Q A Q U I N Environmental Health Department <br /> COUNTY— <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 by APPLICANT <br /> 16 <br /> Business Name lck Ice Ctect-A— 74ILq <br /> Owner/Operator Nameej,ttAA <br /> Business Mailing Address 33�0a ;;,�f�aZ4— <br /> CityLk� /S'tateC�Zip�Bus. Ph.5(0C.�4zrn�0 Alt. Ph. <br /> I, 44AW J �yl , hereby state that the above information is current,true and correct to <br /> the best of my knovAdge 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 penalties. <br /> Signature :Bra. J( — Date /, 0-21 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 1Ck Qo;4CL CPC- YAm FA# <br /> Address 39 /z? F m J ni F_ R e y c Bus. Phone <br /> City S7'a CK' T'ory ZipcA ct 5'D,--S Own r�perator G1 <br /> -moi 0 <br /> Check all appropriate services provided: 0 1 A <br /> 0Na <br /> ❑ Wastewater disposal 0 3-compartment sink 01-lectrical hook-ups M <br /> ❑ Solid waste disposal Cl Food preparation 11,,foilet and handwashing 0 3 0 <br /> Z = <br /> ❑ Hot & Cold water for cleaning 18'Store refrigerated food ❑ Potable water m F) <br /> ❑ Store dry food/supplies QYOvernight parking ❑ Vehicle wash > ;U 0 <br /> I, hereby state that the information I have provided is current,true and CA'to <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility C m D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the fill .� <br /> commissary owner shall notify the EHD immediately. <br /> Signature La/� s.. :�, Date <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 www.sjgov.org/ehd <br />