Laserfiche WebLink
S-A N j OAO U I N nr ironmentai Health <br /> COMMISSARY AGREEMENT <br /> Mobiie Food i=aci;jty Caterer <br /> Complete sections ] and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by A��;.fCANT <br /> Business Name c Lic. Plate#__ g �2 <br /> Owner!Operator Nam m ;C exp,r oS <br /> Business Mailing Address <br /> City-114d t State G)-Zip-9 5 2�O Bus. Ph, Alt. Ph. <br /> I, , hereby state that the above information is current, true and correct-.c <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 /> 2. To be completed b Y OWNER/CFERATOR <br /> Commissary Name r7 Z,+-e C 6 FA# <br /> Address {OZO Bus. Phone�0�) Z Z ZI y <br /> City dl Zip,q&Zu0 Owner/Operator ftSM 004p{U� <br /> Check all appropriate services provided.- <br /> 4 Wastewater disposal �2; 3-compartment sink Electrical hook-ups <br /> 21 Solid waste disposal 0 Food preparation Rf Toilet and handwashing <br /> 0 Hot & Cold water for cleaning Z Store refrigerated food a Potable water <br /> "Z Store dry food/supplies , Overnight parking 4 Vehicle wash <br /> 1' PfZ if cc, , hereby state that the information I have provided is current. true and <br /> correct to the best o my knowledge, and meets the California Health &Safety Code requirements. Jf 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 the EHD immediately. <br /> Signature na�e ')� L2-Lt L,�s;- <br /> L <br /> To be coin ed Joaquin Co. <br /> The cc—missary s .ocated ir, County. 7-e above food fac ':y mee s ­e <br /> commissary requirements 'gin Caiifornia Health & Safety Code. Tne above checked services are available a- --ne <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> r.v:. _c S:.CC:. .. Ca =crn'a . 2�i5 T -2:-= 438-342C F 209 464'f�".38 5 - <br />