Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br />--COUNTY— <br />Greomess 9rcws here. <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 />�iwc <br />Business Name � � � �n,aLic. Plate #yriV/4 G 7 G/ <br />Owner/Operator Name 1 /: 4-) <br />Business Mailing Address 36 egc !,4A1C (L) /V/)— <br />C i ty <br />V/)-- <br />City %ice Zlx.) State 64 Zip -9 / 2 Bus. PSE '20 2) �? 3� • 5Si`9 Klt. Ph. <br />I, , hereby state that the above i� 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 Denalties. <br />�L <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary <br />Check all appropriate services provided: <br />Wastewater disposal ©3 -compartment sink GrElectrical hook-ups <br />Solid waste disposal 17 Food preparation 130'Toilet and handwashing <br />131.1iiot & Cold water for cleaning d Store refrigerated food If Potable water <br />Store dry food/supplies CY Overnight parking irvehicle wash <br />I, jZe gZ R , n LO 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 owner shall notify the EHD immediately. — / / <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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />