Laserfiche WebLink
Environmental Health Department <br />1 <br />Lie. Plate # ^0 <br />Date <br />r <br />REHS Signature Date <br />^3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />pCOvernight parking <br />________________________FA#___________________ <br />__________Bus. Phone ^2.09 'T’S <br />Owner/Operator_ <br />SANJOAOUIN <br />-------COUNTY <br />Greatness grows here. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 | www.sjgov.org/ehd <br />Rm 00^13- <br />3. To be completed by the E^QVTIEALTH 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 />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 />11 • To be completed by APPLICANT <br />Electrical hook-ups <br />pCToilet and handwashing <br />Potable water <br />Vehicle wash <br />, 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 />Business Name^ <br />Owner/Operator Name ; h F? VfZ. <br />Business Mailing AddressU (C 'OcC Ve*gT <br />City^S pAhTtUx State ("A'Zip Bus. Ph. ^OQ • ^HAah Ph. <br />I. , 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 an^i penalties. z C <br />SignatureTxX^Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />- TaU i 'r <br />____Zip 9^,2 <br />Commissary Name_ <br />Address 3 5^ <br />CityVpAv_______ <br />Check all appropriate services provided: <br />Wastewater disposal <br />13; Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shaH-jaotify thp EHD immediately. <br />S ignatu re______