Laserfiche WebLink
~ S A N J ❑A Q U I N Environmental Health Department <br /> ' .' ---C O U N T Y <br /> v!t•,�rness :�rUws !3�rE. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 To be-com p le-te&by APP:LICANT <br /> Business Name -C►;O S T ck C v % Lic. Plate#�� <br /> Owner/Operator Name I"cl C z <br /> Business Mailing Address _�V-Zy <br /> City �w C V* °'l StateCvi Zip �l 5'Z��1" Bus. Ph. C?UCH} C� e n t u <br /> `'t Alt. Ph. `-It7l:', -LlO I Ia <br /> I, �e '�U "L°"'�"E't , 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 `3.x. 4'A- .7 Date a --4 a`& <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name C Vt✓ uu FA# <br /> Address 55 �; • Vl V Bus. Phone (UM -7)3�-A- ZS I S <br /> City a Owner/Operator Z <br /> Check all appropriate services provided.- <br /> W Wastewater disposal M"3-compartment sink WElectrical hook-ups <br /> WSolid waste disposal ❑ Food preparation EKToilet and handwashing <br /> t" Hot & Cold water for cleaning €3 Store refrigerated food Potable water <br /> ❑ Store dry food/supplies 111r,"Overnight parking I"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 shall notify the E immediately. rr <br /> Signature 10 Date <br /> 3. To be com leted by t - NVr HEALTH 'urlsdiction bufs d'e of.:San Joa uiIh .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.sjgov.org/ehd <br /> W14 00 6 <br />