Laserfiche WebLink
i <br /> { S A N JOAQUIN Environmental Health Department <br /> --COUNTY--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of Sail Joaquin County also complete section 3. <br /> 1 . To be completed by APPLICANT <br /> Business Name Lic. Plate# <br /> Owner/Operator Name L', <br /> Business Mailing Address <br /> City rjN, State l�/�-Zip 5'2n�2 Bus. Ph�� "�.�1U_t� SL Alt. Ph. <br /> I, SCnu, � 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 p lties. <br /> Signature Date_ 1 <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name C 1� �� �G FA# <br /> Address S`I�� N�iY�r Q Bus. Phone QLGC.-41;5k <br /> City Zip Q2L>5 Owner/Operator s <br /> Check all appropriate services provided: &S'_" <br /> tV} Ti <br /> w <br /> 'Wastewater disposal `M�'3-compartment sink Electrical hook-ups O0 <br /> p Solid waste disposal © Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning [3 Store refrigerated food E3 Potable water 0 171 G) <br /> ? O <br /> Z <br /> 0 Store dry food/supplies Overnight parking 0 Vehicle wash Z — <br /> n <br /> 1, M �� hereby state that the information I have provided is current, true a* ; m <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food fac&n n <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, It C M <br /> commissary owner shall notify the EHD immediately. U m n <br /> i' <br /> Signature s-- �,' Date L � 11 3 <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 /> 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 /> P1Q2jD00z-1"7 <br />