Laserfiche WebLink
Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate # <br />Date <br />g'-Date <br />Date REHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Commissary Name <br />Address / Y4? I <br />Zip. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />-Er Electrical hook-ups <br />4ZTToilet and handwashing <br />Potable water <br />Vehicle wash <br />1. To be completed by APPLICANT <br />SAN JOAOUIN <br />------COUNTY------- <br />Grrufness Q/oivs heri?. <br />0^3-compartment sink <br />0^Food preparation <br />ET 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 notify the EHD immediately. <br />Signature <br />Business Name <br />Owner/Operator Name <br />Business Mailing Address / A/ <br />city/^YY^r^j Stated Zip ^S^JBus. Ph. Alt. Ph. <br />17 , 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 <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 tyflD ifjthe status of their operating permit changes. <br />2. To be completed by COMMISSARY OWNER/OPERATOR___________ _ <br />6/f PS, 0^1 Co ^7 /n FA# <br />/ d Bus. Phone( 6? 3^-" o <br />City ziP Owner/Operator -4- <br />Check all appropriate services provided: <br />□'‘Wastewater disposal <br />Ef Solid waste disposal <br />Ef Hot & Cold water for cleaning <br />H'"Store dry food/supplies <br />i, 'Be/'/rg/') <br />Olivero^Disuin '» <br />Com_2j£<ary <br />145 S’Xilroy Rd <br />Turlock, CA 953r ’ <br />209-634-2000