Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br />Date <br />REHS Signature.Date <br />Bus. Phone <br />Owner/Operator <br />Lie. Plate <br />Date <br />W'A".V.S gCV.C'C 5“2 <br />Pg-isCDSzq <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 7 and 2 If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br /> <br />Business Namebrand Bui^ZS' Cg>>2€rcfa/ <br />Owner/O perato r N a me H FL <br />Business Mailing Address^70^0 <br />CityAjAfriftj StateCA^ip^^d) Bus. PhgX^ Alt PhfecV <br />1 hereby state that the above information is current, true and correct :c <br />the oest 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 ants penalties. <br />Signature <br />2. To be completed OWNER/OREmWR <br />Commissary Name flZf <br />Address <br />City C Zip <br />Check all appropriate services provided: <br />^Wastewater disposal SS^compartment sink Electrical hook-ups <br />□K^olid waste disposal (AiJFood preparation ^D/Toilet and handwashing <br />S^Hot & Coid water for cleaning (6/Store refrigerated food iZLotabie water <br />JZ^tore dry food/suppiies Z^vernight parking 2/Vehicie wash <br />i./I ____. 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, l-'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 />S i g n a t u re____ <br />'868 E. Hazeitc-Avenue StccKtcn. California 35205 T 203 468-3420 F 203 464-0'38 <br />FA#_ <br />7,77- <br />S. To be completed by ttMMOft' HBMLTH iurisefeteB aatewte 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.