Laserfiche WebLink
a <br /> SAN JOAQUIN Environmental Health Departments <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 l SAP)2o S Lic. Plate#'B <br /> Owner/Operator Name T P_( k-A :7�r) I-At) <br /> Business Mailing Address- '_� I I ZS SG:--&OeA JUIJAU S 7 <br /> City 'S 7�/_--T) Mate (40p �S`Bus. Ph. 30� ?J1�4U�It. Ph. <br /> I, C—/Zt k.F4 , 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�jg/altiesi c // <br /> Signature J S Date <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> / r <br /> Commissary Name'' /, (/ U/n 1 ��, cy S�'�Q� FA# <br /> Address - 4/yy 'S. Bus. Phone ?o9 SL,, l <br /> City 12�ac,ic6,1 Zip 9<� ZZob Owner/Operator rz 1�'brc� <br /> Check all appropriate services provided: <br /> [���/Wastewater disposal W3-compartment sink P-jIlectrical hook-ups <br /> 2 Solid waste disposal — Food preparation N_ Toilet and handwashing <br /> KFiot& Cold water for cleaning '14/ <br /> Store refrigerated food JPotable water <br /> 0 Store dry food/supplies Overnight parking i_-± Vehicle wash <br /> I, ��l� S \Z-t/1' 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 /> Signature "---- - Date A 2�i <br /> 3. To be completed 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 /> RENS 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 />