Laserfiche WebLink
SANJOAOUIN Environmental Health Department <br />I <br />Date <br />Date <br />REHS Signature.Date <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />I, v <br />correc <br />operator fails to comph <br />commissary owner^hs" <br />Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | I 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Wastewater disposal <br />Solid waste disposal <br />^9 Hot & Cold water for cleaning <br />p Store dry food/supplies <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 />| 1. To be completed by APPLICANfBg^ <br />Business Name f (J J <br />Owner/Operator Name <br />Business Mailing Address I ^ (<? | _________________ <br />City yfOC/CTcrA) State Cfizip^S^ Bus. Ph. 2oQ " SAx) (o 2 ^ah. Ph.2o^-G<fS <br />C/ , 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, Date <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name O L) aJ 0 I Aj (~i <br />Address, nn s■ odicc <br />city 3ToCaCY0A3 ZjD Qs 26 U <br />Check all appropriate services provided: <br />3-compartment sink <br />P Food preparation <br />Store refrigerated food <br />Overnight parking <br />, hereby state that the information I have provided is current, true and <br />to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />ith the conditions of this agreement, or if this agreement is modified or cancelled, the <br />JfJ^the EHD immediately. . <br /> (Ji ib <br />3. To 6^ 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. <br />SANJOAOUIN <br />6 ' ------COUNTY------ <br />r bregfnpss nere. <br />______Bus. Phone 2-^ ~ / C <br />Owner/Operator Pc’S n IP // / <br />_____ _________ ’I <br />___________Lie. Plate# fcXSV / <br />E- <br />S7