Laserfiche WebLink
1.1J <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <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 />To be completed by APPLIGANI <br />Business Name #0,(144 <br />„ <br />Owner/Operator Name 'ciair/e <br />Business Mailing Address -kn S • So.ti <br />City State Zip ic31,1(C2 Bus. 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 andieryfties. <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Lic. Plate # 47 -N3q Zf <br /> <br />Si <br /> <br />Alt. <br /> <br />Signature te•o/. Date <br />Commissary Name <br />Address <br />City <br />Check all appropriate services provided: <br />FA# <br />7:) <br />Owner/Operator i \i?(MC) CMOCI /NOIV,(1(10{-00 <br />Bus. Phone(2. oq) 2214 - 3 3 ,1-( <br />-14:1 Wastewater disposal <br />ka Solid waste disposal <br />Vit Hot & Cold water for cleaning <br />Store dry food/supplies <br />4.3-compartment sink <br />El Food preparation <br />Store refrigerated food <br />Overnight parking <br />,12t, Electrical hook-ups <br />etiToilet and handwashing <br />l. Potable water <br />,E(Vehicle wash <br />I, Ornvf\nt--)Yr(v\ hereby state that the information I have provided is current, true and <br />correct to the best of-fny 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 n ti me EHD immediately. <br />Date OZ1Z-00 <br />3. To be completed by the ENV HEALTLI _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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Pt SLt -S3 <br />Signature