Laserfiche WebLink
2 <br />Date <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 />Environmental Health Department <br />FA# <br />(507) <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1. To be completed by APPLICANT <br />Business Name_//1£_^ <br />Owner/Operator Name ffi/ZztTy/T? QorJi <br />Business Mailing Address I! <br />City g)6ll4~ C ____ _____________________;State CAzip us. Ph^pq- *1^ 2 - HijLi^it. ph. 2CQ-Ucf)8" <br />I. ^^“7 ■ hereby state lhat 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 <br />^•F-______Bus. Phone <br />Owner/Operator <2^'^————— <br />Ca^^lectrical hook-ups <br />EkToilet and handwashing <br />□PFotable water <br />DFA/ehicle wash <br />SAN JOAQUIN <br />• COUNTY------ <br />Grratnc’-;; ■: w i >< <br />Date qr'J I <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name_ <br />Ad d re s s ZCT a <br />City —)Qf'Zip <br />Check all appropriate services provided: <br />[^/Vastewater disposal t&^compartment sink <br />E^oHd waste disposal PreParation <br />CTT1o7& Cold water for cleaning ^^/Stopa-refrigerated food <br />EP^tore dry food/supplies [Jpdvernight parking <br />I.________^22^—^_______________' hereby state that the information 1 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 oi cancelled, the <br />commissary owner shall notify the EHD immediately. <br />Signature Date------------ <br />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. 1 he above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> n <br />Lie. Plate #