Laserfiche WebLink
Environmental Health Department <br />Complete sections 1 and 2. <br />’A.-WDate <br />REHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ❖ Caterer <br />Lie. Plate # <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 />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. The above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />• * • <br />■ ■-■'k/_pq£ <br />% SAN JOAQUIN <br />< ------COUNTY------- <br />Greatness grows here. <br />tn 3 <br />H %> C O ± ? <br />S’ <br />c Q m rr > XJ ™ <br /><© > 2 <br />cji < i <br />m 2 <br />If your commissary is located outside of San Joaquin County also complete section 3. <br />pl. To be completed by APPLICANT <br />Business Name N\cqa P/Vlcwaj <br />Owner/Operator Name ftp KE K 0 <br />Business Mailing Address 3ZO £ Zl(/£ < <br />City Lofil State Pl^ZiD 932^0 Bus. Ph.Alt. Ph. <br />-------------------------------------------------------------- - 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 Date V 7.-7-£ <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name F I C )< /jZ Q & C CP. £ 0 (T)FA#__ <br />Address_ J xr? /A V Bus. Phone ^<7- <br />City Zip Ow?ier/ODerator <br />Check all appropriate services provided: <br />O Wastewater disposal 3-compartment sink Electrical hook-ups <br /> Solid waste disposal H Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food £3 Potable water <br /> Store dry food/supplies 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