Laserfiche WebLink
/ .'.1pa`gN c <br />. el <br />Health Department <br />SAN,'JQAQUIN <br />—COUNTY— <br />. -Op .` Greatness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility t Caterer <br />Complete sections 1 and 2 If your commissary is located outside of San Joaquin County also complete section 3. <br />• • . - . v� _'. i. �� '�INMI <br />State&LZipj,Cda0 _ Bus. -/SS9DAIt. PQ06/- z%30-%ya � <br />I,Cf 1114 'O/tl hereby state that the above information is current, true and correct to <br />the best of my kn ledge and agree to util'¢e 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' in d, the permit holder must notify the EHD. Failure to notify this office may result in' permit <br />revocation penalti <br />Siqnatur Date //� -G -a <br />Check all appropriate services provided: <br />ij Wastewater disposal <br />116 Solid waste disposal <br />❑ Hot & Cold water for cleaning <br />❑ Stprg dry <br />I, C VA11 I-1 / �ftNlg, <br />correct to the bp"f my knowledge, <br />operator fajielo comply with the V <br />commissy-tfy ower shall notify the <br />❑ 3 -compartment sink <br />❑ Food preparation <br />❑ Store refrigerated food <br />❑ Overnight parking <br />❑ Electrical hook-ups <br />❑ Toilet and handwashing <br />❑ Potable water <br />Vehicle wash <br />'f- hereby state that the information I have provided is current, true and <br />4ts the California Health & Safety Code requirements. If the food facility <br />is of this agreement, or if this agreement is modified or cancelled, the <br />- G — A q- <br />3jTo.be cg` m I ed6 ,the ,Fw��LI;EAL+TH''ur�s fiction m ts'de o a : un:Co. <br />Jo <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. P.lease notify EHD if the status of their operating permit changes. <br />REHS <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 />