Laserfiche WebLink
SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> Greatness gre r he,e. <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 /> 1. To be completed by APPLICANT <br /> Business Name et-eAd Lic. Plate# qf�,FZI`3 <br /> Owner/Operator Name <br /> Business Mailing Address o� Q <br /> City---7 0 ZI? <br /> t i Zip �so�ILO Bus. Ph.,2 497 x//01•Loja%Alt. Ph. <br /> 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 /> Signature23C_5 u5 T-a`"" "rQ \Q fckf c0 Date ,Z — <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L (k C 0 " e�C Ct C&-' C oY J_) FA# <br /> Address 2 C1 0 6 !F_ . }\Urdcac_ 'Lo- C,q Bus. Phone 2_a c-1 — 4 -7U <br /> City Sic-K Wn Zip 15-105 Owner/Operator 07. 2. h Q1 n e <br /> Check all appropriate services provided: <br /> a Wastewater disposal �( .-compartment sink Electrical hook-ups <br /> jj(Solid waste disposal 13 Food preparation >d—Toilet and handwashing <br /> 5LHot& Cold water for cleaning E3 Store refrigerated food `Potable water <br /> D Se food/su lies OvernC�Light parkin <br /> Y Vehicle wash <br /> oo n/N i En n1�4 !� <br /> 1, rc' -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 fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary 9.v7per shall notify the immediately. <br /> Signature —Date—g <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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />