Laserfiche WebLink
SAW]MUIN Environmental Health Department <br />COUNTY <br />COMMISSARY <br />OUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility a Caterer <br />Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name � �I C � led) Lic. Plate # '19Z 7 Z 9 2 <br />Owner/Operator Name S U I/ C� G Y 1(A l �2 � X <br />V j5-32 3Z <br />Business Mailing Address <br />City _State,,'-LZip q �i /; 3 Bus. Ph. Alt. Ph. <br />I, 1 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 —Date 1 /3 16 -2 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName LA FA# <br />Address SqGlC�� E �fu-A'�a WCaN Bus. Phone ``��i <br />City ��C!C KEc✓� Zip SIS 205 Owner/Operator Cin: A c e,. t <br />Check all appropriate services provided: <br />Wastewater disposal '2 3 -compartment sink EI cal hook-ups <br />Vd ,olid waste disposal s Food preparation T 'let and handwashing <br />Hot & Cold water for cleaning a St refrigerated food /�C-ble water <br />M Store dry food/suppiies Ovemight parking E� Vehicle wash <br />1, 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 />commissarylLweer 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 Signature J%1 Date <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov_org/ehd <br />