Laserfiche WebLink
" <br />°Pco,SANADAQUIN Environmental Health Department <br />2 yl <br />LE' ` —COUNTY— <br />cGreotness grows here. <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 movciSCOS Sind Loc, <br />Owner/Operator I <br />Business Mailing <br />Lic. Plate# 40J 3:5-'--7(D <br />City C.A� State C4 ZipISI-L-6Bus. Ph. U9-GO.31P1U Alt. Ph! 001 •It0-3,00131D <br />I, J05e WeJ�ls C1M �6f� ereby 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. i <br />MMISSARY_ <br />Commissary Na <br />City <br />Check all appropriate services provided: <br />16 Wastewater disposal t3 3 -compartment sink <br />Date 12 <br />RATOR- <br />_FA# <br />d Electrical hook-ups <br />lb Solid waste disposal O Food preparation Toilet and handwashing <br />lb Hot & Cold water for cleaning 13 Store refrigerated food Potable water <br />0 We dry food/suDplies 10 Overnight parking 16 Vehicle wash <br />I, �w/V/;� /,LLF41Vr &'1)F7 - hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge d meets the California Health & Safety Code requirements. If the food facility <br />operator fails t6Fomply with thitions of this agreement, or if this agreement is modified or cancelled, the <br />shall noti a EHD immedia d( <br />°Gr e 1�4ii�a�ii nate _A0 <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 <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 />