Laserfiche WebLink
{ <br /> U'"` SANslOAQUIN <br /> Environmental Health Department <br /> COUNTY— <br /> ��� Grectness grog%s 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 /> �rANI• <br /> Business Name f S 6 ic.Plate# p2 <br /> Owner/Operator Name r t o UZCC) <br /> Business Mallin Address 3 Y-d. <br /> City State�Zip 25ISBus. Ph. t. P . <br /> I, <br /> C-Qhereby state that the above information is current,true and correct to <br /> the best f 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 enalties <br /> CN\-4c- 4 Oroz <br /> Signature Date �— <br /> Commissary Name0-nMMI 4V;2A 47_�e C G FA# <br /> Addresst197 O A_fG S+ Bus. Phon <br /> City �� Zip 9S 2---41D Owner/Operator Cjc <br /> G <br /> Check all appropriate services provided: <br /> Wastewater disposal g 3-compartment sink S Electri I hook-ups <br /> (� Solid waste disposal ❑ od preparation V Toilet and handwashing <br /> �"ot& Cold water for cleaning 17,store refrigerated food 11�Potabl a water <br /> Store dry food/supplies `y Overnight parking MVehicle wash <br /> I, ODLA wLw c G hereby state that the information I have provi ed is current,true and <br /> correct to the best of 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 th HD immediately. <br /> Signature Date Z Z 7 Z 2- <br /> The <br /> The commissary is located in 1 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 <br /> Date_-1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />