Laserfiche WebLink
SAN IOAQU IN Environmental Health Department <br /> —COUNTY— <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 completed by APPLICANT <br /> Business Name UPAS L f - Lic. Plate <br /> Owner/Operator Name <br /> Busine s Mail'ng Address t <br /> CiStat Zip us. Ph. :7la1 lt. Ph. <br /> I, fYl , hereby state that the above information is current,true and correct to <br /> the best of my knowledgOjnd agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San J uin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is disconti ue ,t permit holder must notify the EHD. Failure to notify this office may result in permit. <br /> revocation ani' <br /> n p alta s. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissaryr Name ffll VVV �nGS 'J FA# 2, <br /> Add�res�^s 4 J�r7V � . ` v ren, rft1V)A S—�IF' Bus. Phronne`�/�� <br /> CityLL4-�I Zip vl � Owner/Operator W /'�� <br /> Check all appropriate services provided: LOVE'S TRAVEL STOP#538 <br /> Wastewater disposal e3-compartment sink ❑ 'tI�T7C`"Cd'a gSVN ROAD <br /> ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot& Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies ( Overnight parking ❑ Vehicle wash <br /> I, , 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 omply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary/owner hal notifythd'l'HDimmediately. �/� I/ <br /> Signature / �'�I%� Date <br /> I C 1 L� I <br /> 3. Tobe com leted by the ENV HEALTH jurisdiction outside of San Joa uin 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 />