Laserfiche WebLink
Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date <br />Date <br />DateREHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />Wastewater disposal <br />Solid waste disposal <br />P Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i, rVoSA- <br />f----------u__x .---------- <br />operator fails to comply with <br />commissary owner^stTWjf’ <br />S ig n atu re <br /> Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />3. Toloe 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 />------COUNTY------ <br />Greatness grows here. <br />Commissary Name 0 AJ i 0 AJ "IclZl AS G? 1 £ (J Ci£ Cc ___________________ <br />Address I"] ) H .3' L) M 10 43 S 1____________Bus. Phone V' <br />City SIOGCVO C Zip G Owner/Operator ^.08 > /UT <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />____, hereby state that the information I have provided is current, true and <br />correctto the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />conditions of this agreement, or if this agreement is modified or cancelled, the <br />)EHD immediately. . <br />1. To be completed by APPLICANT_________________________________ <br />Business Name "TAC-CkS tsL 0 ft 2^ Lie. Plate# I <br />Owner/Operator Name AJ |€ I 0 ,SZ) tJC /7/? 1 <br />Business Mailing Address 3^/0 <br />City 5700^20^ Stated Zip AS2Bus. Ph.S/Q-A^ ~kSZA Alt. Ph. <br />I, MAl^lO 3 7^- 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 pena^ties^^7 ^^7 l <br /> <br />S ig n atu re Y^z<^Date <br />1 2. To be completed by COMMISSARY OWNER/OPERATOR