Laserfiche WebLink
Opat4N C. <br />SAN: JOAQUIN Environmental Health Department <br />i—COUNTY— <br />:;,r` Greotness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections f and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br />1, To be completed bg APPLI ANT <br />/1) <br />Business Name J uary-I Lic- Plate # 7Z - 2-Z <br />Owner/Operator <br />Business Mailing Address '7-/(,:p W KAJa li61. (r n iUv z <br />City/A� r Stat<LZi0Bus. Ph. Alt. Ph. <br />I, sA k)ot, y z? 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 />Address ZH'4{O S. 4yQor-4- t zx_ _ us. Phone��- S-61- /5V-6-6 <br />City siabL' l Zip��Owner/Operator 34pG&8 26A614) <br />Check all appropriate services provided:: / <br />Wastewater disposal l3 -compartment sink —M/Electrical hook-ups <br />)Solid waste disposal Y/�ood preparation E3' Toilet and handwashing <br />fiHot & Cold water for cleaning ®/Store refrigerated food Ise' Potable water <br />Store dry food/supplies Q Overnight parking pNehicle wash <br />I,g::!4� � 6: c: hereby state that the information 1 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 shall notify the EHD immediately. <br />Signature Date Z <br />3. To be -corn leted'b the ENV.HEALTH 'urisdietion outside of -San Jo'a'q tin 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 4640138 1 www.sjgov.org/ehd <br />