Laserfiche WebLink
SAN,IOAQUIN <br />—COUNTY— <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility s Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />d 31 c�a7 fi Y`S, 3 a xr .. Tobe corn leted.b APPLICANT" <br />Business Name <br />Owner/Operator <br />Plate # 12 1uc 2 <br />Business Mailing Address 1020 W eSt OAK Street <br />City. C4,ock-i-on State_CA-_Zip g52D3 Bus. Ph. guy -012-3233 Alt. Ph. Z& 3-lk/ �5 <br />I, JC2 a i I ley r>1n FUrYI{es 3i2 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 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 penalties. <br />Signature.//,d'1l7X�Zi % ' Date % % <br />Address /��l S SCy6i U/Z i a Jf Bus. Phone17A I I,-gT71 <br />City b $� f r Zip-- Owner/Operator 612 <br />Check all appropriate services provided: / <br />V Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />E1 Store dry food�/($upplies <br />�_4>11 rU , hereby state that the information I have provided is current, true and <br />to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />it fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />© 3 -compartment sink <br />13 Food preparation <br />E3 Store refrigerated food <br />P- Overnight parking <br />FA Electrical hook-ups <br />'"Toilet and handwashing <br />13 Potable water <br />% Vehicle wash <br />owner <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 />