Laserfiche WebLink
Environmental Health Department <br />1. To be completed by APPLICANT <br />Lie. Plate # <br />Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />ehicle wash <br />Date <br />| 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />Date REHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 lwww.sjgov.org/ehd <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 />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />0^7 S' K <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />------COUNTY— <br />Greotness grows here. <br />CommissaryName FA# <br />Address ^4-Bus. Phone " 855 <br />City A zip 7Z Owner/Operator <br />Check all appropriate services provided: <br />[^T/Vastewater disposal [^^compartment sink <br />Q^olid waste disposal /^CpFood preparation <br />Ekfiot & Cold water for cleaning (Store refrigerated food <br />QR^tore dry food/supplies [J-''6vemight parking <br />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. 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 immediately. <br />Signature <br />BusinessName ChALT- - <br />Owner/OperatorName < C Z <br />Business Mailing Address (±><V\6/V<\\ <br />City gWELoyv State QY Zipq,5~?lZ- Bus. Ph. CSV^ZlS-'T^AIt. Ph.7C% cfrC-ol X I <br />I,, 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