Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> 1V U'i —COUNTY— <br /> Greatness 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 <br /> qq APPLICANT// <br /> Business Name�knwQ f�4isPr! r�(JD Lic. Plate# S1Uyp(�29 <br /> Owner/Operator Name / �q tzT 1 14rrn&5 <br /> Business Mailing Address <br /> /9ra37 �5 /LUY 9�� <br /> City StateC, Zip W3b Bus. Ph. Alt. Ph- <br /> 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 pe alties. <br /> Signature ertryo Date 8`'c;t3 –0 <br /> 2. To be com feted by COMMISSARY OWNER/OPERATOR 4 <br /> Commissary Name C / / U FA# <br /> Address / ✓ e Bus. Phone —oS <br /> City L��' Zip Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink Electrical hook-ups <br /> tKSolid waste disposal 0 Food preparation bCToilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated food ErPotable water <br /> 0 Store dry <br /> yffood.//ssupplieess Of Overnight parking Vehicle wash <br /> I, y6 //U 11711,24W. <br /> li`1lls,UC , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowl,dge, 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 HD i diately. <br /> Signature Date j��.J•Z <br /> 3. To b 3 completed bV the EM 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 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 />