Laserfiche WebLink
SANAOAQUIN <br /> <br />Environmental Health Department <br />COUNTY — <br />Greatness gripws 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 />To be completed by APPLICANT <br />Business Name © <br />Owner/Operator Name 0 K---"tQ.rrw-11,12_ Ery\okevt::-42.- <br />Business Mailing Address 6 Cf.D1 4AvveN--\ C3V,(-; J-(2- tbr <br />City -GAT c--• State CA Zip ck S')--LO Bus. Ph. Alt. Ph. <br />I,e‘C.--\.Q tw.A./.12- , 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 Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 5 ‘1/4.•,/ \4: <br />Address \\O E. \ ,cocrk_c. s \-- Bus. Phone <br />City 5 Zip 0 <br />Check all appropriate services provided: <br />ET-Wastewater disposal 0/3-compartment sink La/Electrical hook-ups <br />EtrSolid waste disposal 0/Food preparation r.roilet and handwashing <br />3/Hot & Cold water for cleaning Ur/Store refrigerated food 0/Potable water <br />"Store dry food/supplies Dr-Gverrrighi pdrking ia-ttitftit-tAttaeil <br />`SO-0, c-Q , 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 fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner sh otify the D immediately. <br />Signature <br />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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Lic. Plate # <br />Owner/Operator \nc_ <br />Date -3 - <br />wosqvicito