Laserfiche WebLink
S Q N ..J OA O U IN Environmental Health Department <br /> _—COUNTY <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections i and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name \a \' C 1 Lic. Plate# <br /> Owner/Operator Name�f'�'L'�p,r'1� �d1��r<�\e <br /> Business Mailing Address <br /> City�� y_ State C' Zip Bus. Ph.(19)a2A All Alt. Ph. <br /> 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 3- <br /> 2. To e completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address r Bus. Phone <br /> City L/-1�61/1 Zip ` Owner/Operator �o <br /> Check all appropriate services provided: <br /> Wastewater disposal L,Z"3-compa rime nt sink Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaning ❑ Store refrigerated food Potable water <br /> ❑ Store dry <br /> ?food/supplies �'Overnight parking ( Vehicle wash <br /> I, z� e4h , 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 irrigiediately. <br /> Signature Date <br /> 1.3. 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. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov,orgiehd <br /> KI%N*5 <br />