Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> COMMISSARY <br /> OUNTYCOMMISSARY 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 /> 1. To be completed by APPLICANT <br /> Business Name)-yt i n n A-p. Q k n t �j e C Lic. Plate#�'��6 2 r-) Ua <br /> Owner/Operator Name M n r YvN ok Ik Cie C (n i ct <br /> Business Mailing Address_? ZZ Ila <br /> City. TTv4r I State-C&Zip 953ins4 Bus. Ph. Alt. Ph CS l0 7 6 7- <br /> I, �)Q N r'-e C-1.,� �jc, , 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'i';. �_ Date <br /> s <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name /i ;,; >> , . :; r %tC FA# <br /> Address Bus. Phone " 'Z e > <br /> City i i"i' Zip 5Z`7 Owner/Operator }>;r,f;i <br /> Check all appropriate services provided: <br /> Q Wastewater disposal R 3-compartment sink 10 Electrical hook-ups <br /> Ef Solid waste disposal 4Y Food preparation Q Toilet and handwashing <br /> 13 Hot & Cold water for cleaning 10 Store refrigerated food m Potable water <br /> WStore dry food/supplies Q>Overnight parking W-Vehicle wash <br /> I, G''r e,j, c ''W X A N r L , 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 Zl,e � ,- Date '1 5 l2- <br /> 7 <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 /> 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 />