Laserfiche WebLink
Environmental Health Department <br />Date <br />Date <br />REHS Signature Date <br />. Electrical hook-ups <br />Toilet and handwashing <br />of Potable water <br />Ef Vehicle wash <br />SAN JOAQUIN <br />------COUNTY------ <br />Greotnffis grows here. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 (www.sjgov.org/ehd <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name { ftzf a , Cx (" i, <br />Address 2- <br />City Zip yp? <br />Check all appropriate services provided: <br />BT Wastewater disposal <br />gf Solid waste disposal <br />V Hot & Cold water for cleaning <br />OfStore^dry food/supplies <br />I. <br />FA#__________________ <br />—Bus. Phone 2^? C - Qj / — / Y6 €• <br />Cj Q Owner/Qperator t c <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 />a tpA |ova <br />Business Name cnY/S VreS Io/A01 Lie. Plate # <br />Owner/Operator Name ^/' Z. <br />Business Mailing Address H C h C TO KCC p, j <br /> City S j-nc yAo V) StateCA Zip Bus. Ph^07? S)8 AogRAIt 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 and penalties. <br />Signature \/<q / y] <br />□T 3-compartment sink <br />tjf Food preparation <br />Store refrigerated food <br />0 Overnight parking <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 />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notifyrthe EHD immediately. > <br />Signature ------------------------------------Date <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.