Laserfiche WebLink
SAN JO A Q O i N Environmental Health Department <br />COUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility + Caterer <br />Complete sections land 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />Business <br />Owner/Operator <br />City <br />Plate # <br />I, \ N \ut'-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 d)continued jMe permit how must notify1he EHD,,Failure to notify this office may result in permit <br />'016/2 <br />12. To be completed by COMKIISSARY OWNER/OPERATOR <br />r S <br />Commissary Name l 0C (U)J CO�fd&J—j 11CtUc5t) FA# <br />Address k� 0 u (` !C 2 Bus. Phone <br />City SLC>Ct VD0 Zip J 2 Owner/Operator R it -f 4l- <br />Check all appropriate services provided: W e Qq_x_ 5L, ,pA42- G Yw1yvU12u � <br />M Wastewater disposal A 3 -compartment sink � 99 Electrical hook-ups <br />;3 Solid waste disposal B Food preparation 119 Toilet and handwashing <br />v4 Hot & Cold water for cleaning Store refrigerated food 1.-J Potable water <br />Store dry food/supplies <br />� Ij Overnight parking, I'..' Vehicle wash <br />22[jes_, 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 sJaall ngt* 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 <br />1868 E. Hazelton Avenue i Stockton, California 95205 1 T i09 468-3420 1 F 209 464-0138 1 wvvw.sjgov.org/ehd <br />