Laserfiche WebLink
SANJOAQUIN Environmental Health Department <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 1 , , <br /> Business Name r S Lic.Plate W <br /> Owner/Operator Name 1 1 S <br /> Busines Maili Address J�e � j�C�J <br /> City�'�tateCZip Bus. I is l �) J �s�" -Ph. <br /> hereby state at 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 penalti <br /> Signature L.I, Axl Date 6 Ifo& <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> -fiCommissary Nam (1 9v t� <br /> Address �J 111 Bus. Phone <br /> City ( Zip _qSOwner/Operator Va DY"' w f v <br /> Cho all appropriate services provided: <br /> �d/Wastewater disposal Q-- compartment sink electrical hook-ups <br /> g'Solid waste disposal i-ood preparation Er Toilet and handwashing <br /> B'Hot& Cold water for cleaning O St re refrigerated food U3 Potable water <br /> Store dry food/supplies Overnight parkingehicle 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 ' ly with the conditions of this agreement, o if this agreement is odified or cancelled, the <br /> commissary0 sh otify HD' lately. ^ <br /> Signature �!` ��ri11/ 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />