Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> . COUNTY-- <br /> S OuNiY---- <br /> . :.,_ <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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�, tf�",c; r Lic. Plate# 6 ;1J c��J <br /> Owner[Operator Nam2 DBrm.) <br /> Business Mailing Address_ _ �(� ( J ,� d7 <br /> City_S70CaCr1A� stateZip_gT- <br /> gus. Ph. 7 Alt. Ph. <br /> 1, (S0,9Mj )14/4LAA Vii, L , 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 /> Signature � 9 f i Date (� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name_;.t)l0A_) CAZteLX/C7 T&Ce,_ liilye t) FA# <br /> Address-)-7J7 8. QAjio,0 S1 Bus. Phone 2-oCl ofAict If <br /> City �'7 0 C.K�1690 Zip q S () - OwnerfOperator 71'ZAt�) <br /> Check all appropriate services provided: jV0 S7006 <br /> ` Wastewater disposal 12, 3-compartment sink Ll Electrical hook-ups <br /> Solid waste disposal M Food preparation i Toilet and handwashing <br /> Hot&Cold water for cleaning M Store refrigerated food 0 Potable water <br /> D Store dry food/supplies I Overnight parking R Vehicle wash <br /> 1 -1Le ,hereby state that the information I 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 falls to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o er al otify the EHD immediately. <br /> Signature Date i9 - 16 -,26}Z3 <br /> 3. To be completed by the ENV 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 1 Siockton, California 952051 T 209 468-3420 1 F 209 464-0938 1 www.sigov.org/ehd <br />