Laserfiche WebLink
S A N _J O A Q U I N Environmental Health Department <br /> COMMISSARY AGREEMENT I <br /> Mobile Food Facility a 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 APPLIC <br /> Business Name F l eV Lic. Plate# 4 W D 1 510 <br /> ownerlOperator Name <br /> Business Mailing Address Ic uo <br /> City LK c ti, StateCPN Zip�Sas Bus. Ph. Alt. Ph. <br /> 1. ",Ze 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 pe e';altf � <br /> Date L4 ` <br /> 2. To be com feted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name C FA# <br /> Address 5� JcA Ave- Bus. Phone— ZOc( <br /> City L.OLkA Zip GS2-4 D Owner/Operator <br /> Check all appropriate services provided: <br /> &rWastewater disposal N"'3-compartment sink Electrical hook-ups <br /> WSolid waste disposal , ^ ❑ Food preparation U(Toilet and handwashing <br /> WHot& Cold water for cleaning ❑ Store refrigerated food StPotable water <br /> ❑ Stored y f odls pplies E(Overnight parking Vehicle wash <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 sh noti the E mmediately. <br /> Signature Date <br /> 3. To be completed b th 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.sigov.org/ehd <br />