Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name Lic. Plate# <br /> Owner/Operator Name e-, I (7 <br /> Business ailin Address <br /> City����Stat�Zip �S Bus. PhGv f �J Alt. Ph. <br /> hereby state that 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 JoaquinCo ty Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,th6 pe Ider must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date <br /> 2. To be coin feted COMMISSARY OWNER/OPERATOR <br /> Commissary Nam a- QJ4LI a i u <br /> Address '-�tBus. Phone Mi <br /> City Zip1Owner/Operator iono <br /> i <br /> Check all appropriate services provided: <br /> 0--astewater disposal [r-3-compartment sink }Electrical hook-ups <br /> _ Solid waste disposal C�ood preparation p'Toilet and handwashing <br /> KI'/Hot& Cold water for cleaning U-Store refrigerated food potable water <br /> Id Sto^re dry�food/supplies E1 Overnight parking O'�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 comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary <br /> �oneer sh notify the EHD immedAtely. NJ <br /> Signature III 1 I /If Xbe c9t "' II 1 b Date v <br /> To Vompleted''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 />