Laserfiche WebLink
SANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> CrJY , <br /> Greotness 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 //J / <br /> Business Name L,4-64-; (/ Gi%, Lic. Plate# 7(�/���L <br /> Owner/Operator Name <br /> Business Mailing AddressG�t <br /> City r ULlt fir. StateCA,Zip 4 -2/L Bus. Ph. vG)K"i(-qOG t Alt. Ph. <br /> I, 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 /s. Date oS`s'�Z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name � (44_) h. FA# <br /> AddressQQ 00 e', G� Bus. Phone W? &I L Ll –L45 �r0�– <br /> City Zip C ' O/wner/Operator <br /> Check all appropriate services provided: <br /> & Wastewater disposal fa 3-compartment sink Electrical hook-ups <br /> It Solid waste;disposal ❑ Food preparation Lel Toilet and handwashing <br /> tb Hot & Cold water for cleaning ❑ Store refrigerated food t4 Potable water <br /> 0 5�'ore dry food/suppli1ess 19 Overnight parking IA Vehicle wash <br /> I, (/�/rY04 / x7�wl�� +�Z– , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,an meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the itions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary,6�lvner shall notify the HD immediately. <br /> Signature Date <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 /> 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 />