Laserfiche WebLink
SAN IOAQU 1 N Environmental Health Department <br /> ~- COUNTY . <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 APPLICANT <br /> Business Name rTo�wA DbA& Lic. Plate# AA nn <br /> Owner/Operator Name <br /> Business Mailing Address_ � ') {� ynj in L r) <br /> City StateLLZip V) Bus- Ph._2Q+ 3 . E Alt. Ph._�U Ito -cI Loc13 <br /> 1, C ' r pre H '� , hereby state that the above information is current, true and correct to <br /> the best of my Rnowledge and agree tb 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. �1 <br /> Signature r C� JYf yrY- Date U 2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> - Commissary Name Wjinn <br /> Address Bus. P one 0 - 5 qj 0 <br /> City Zip q. -2 b O Owner/Operator r-P Tio <br /> Check all appropriate services provided: 0 V V Y n f ( h <br /> F,a- Wastewater disposal - _p 3 compartment sink "�' Electrical hook-ups <br /> Solid waste disposal 9 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning 01 Store refrigerated food Potable water <br /> Store dry food/suppl- s Overnight parking Vehicle wash <br /> I. , hereby state that the information I have provided is current, true and <br /> correct to the best of m wledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comply -th t conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall n immediately. <br /> Signature Date_*LOUW <br /> 3. To m leted 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.orglehd <br />