Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> --COUNTY— <br /> , <br /> GrraMra gn:•i•.s hero. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility e 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 APPLICANT <br /> Business Name DoIc2 ZC /1 Lic.Plate# <br /> Owner/Operator Name GL ` ,S)A�L '" <br /> Business Mailing Address_ Q x `3%� l` <br /> City ::j"CLb1 StagZip `fy ��J Bus. Ph. %1 -t -3- 1(D� It. Ph. <br /> I, t50..1'C' l fi)Ai a_J _, 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 discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a penalties. r /I <br /> Signature (>\.�ti. Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR. <br /> —F' <br /> Commissary Name L' r 11 i ti, FA# <br /> Address ��� r I I /7 ( Bus. Phone <br /> City Zip C rt Owner/Operator 42 <br /> Check all appropriate services provided: <br /> Wastewater disposal IIR:'�3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal -1 Food preparation )3 Toilet and handwashing <br /> iV Hot& Coldwater for cleaning M&Store refrigerated food 4 Potable water <br /> ,ZStfdry food/ upplies ❑ Overnight parking ❑ Vehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correcl 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 ot'fy the Eimmedi tely. �I <br /> n 1 ZZ� <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH juns0- 17 6,,$ San-Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> IQ commissary requirements in California Health & Safety Code. The aboae checked services are available at the <br /> A above commissary. Please notify EHD if the status of their operating permit changes. <br /> Da' <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.sigov.org/ehd <br />