Laserfiche WebLink
SANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 <br /> by A/PPPLICANT I <br /> Business Name 1 Y t F I � ( C fE Lic.Plate# <br /> Owner/Operator Name 2201 �,Oce� <br /> Business Mailing Address ' q )-,A l L N. it� <br /> City StateLA AhrTo PjS 7fJ?J210O Alt. Ph. <br /> I, y (A-U 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, permit holder ust notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. _ <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address Bus. Phone <br /> City Zip Owner/Operator N <br /> Check all appropriate services provided: p <br /> p Wastewater disposal 0 3-compartment sink Electrical hook-ups � N Z <br /> p Solid waste disposal 0 Food preparation Toilet and handwashing 4 In ') <br /> Ozo <br /> O Hot & Cold water for cleaning Store refrigerated food D Potable water m n <br /> O Store dry food/supplies �Cl,Overnight parking D Vehicle wash > ;am <br /> I, hereby state that the information I have provided is current, true andCh C A <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility." m [Dil <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the." 3 <br /> commissary owner shall notify the EHD immediately. <br /> Signature C .�; Date <br /> 3. To be completed b. .the ENV HEALTH 'urisdiction outside of San Joa , in 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 />