COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN Environmental Health Department COU NTY-- COMMISSARY AGREEMENT Mobile Food Facility ® Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. 1. To be completed by APPLICANT Business Name/yir_r i"k)e z Lic. Plate#4 81 6 gy 1 Owner/Operator Name l(LV;o Te 1l o 7- 44cu-- 1/kie z Business Mailing Address F_ 4- City/yak, le cu— StateA/l Zip q6 3 s E Bus. Ph. 2 09- 70'5-q1 yA41t. Ph. I, , hereby state that the above information is current, true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit revocation and penalties. Signature kP i , yrDate 2. To be completed by COMMISSARY OWNER/OPERATOR Commissary Name rn I C'K pct o _��s_ CRCV1evt FA# Address 3 1-1 1`, L m i 1,1-J5 R o v'Lc- Bus. Phone t� oct^ Cfiv�g� 11 City S7-6> Cly TSN Zip �� g_5 Z�S Owne /r Operator Check all appropriate services provided: n ® Wastewater disposal ❑ 3-compartment sink Electrical hook-ups N ; F3,j Solid waste disposal ❑ Food preparation Toilet and handwashing In Hot & Cold water for cleaning Store refrigerated food ❑ Potable water ? Z ` Stored food/supplies lies Overnight parking ❑ Vehicle wash D X P dry pp � I, hereby state that the information I have provided is current, true and N D 7 correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility N m11 operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the N ' _ commissary owner shall notify the EHD immediately. s Signature �� 'w _� Date ,(^ /u- 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd