Laserfiche WebLink
Yrx, •’ <br />K r*v § ron re U Hs5i''s l-C^s pa f Wve !• ••"' <br />Date <br />J' <br />Date <br />Date.REHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br /> <br />oo^q- <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />SAN JOAQUIN <br />COUM TY <br />0 Electrical hook-ups <br />V Toilet and handwashing <br />X Potable water <br />X Vehicle wash <br />3-compartment sink <br />X Food preparation <br />Store refrigerated food <br />Ci Overnight parking <br />i hereby state that the information I have provided is current, true and <br />knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />1. To be completed by APPLICANT_________ <br />Business Name, <br />Owner/Operator Name Sa, <br />Business Mailing Address, Wl Or i <br />City Stated zip ^7 ??^us. Ph. Ph. <br />I OSA- , 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. o O / / *7 <br />Signature Date ----- <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />I <br />Lie. Plate # /ponsz <br />correct to the best'o <br />operator fails to col <br />commissary <br />Signature <br />3. To l^tompleted 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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name U KJl^ WK <br />Address 0 fl \l N I 0 1^/ 5s P Bus. Phone d S^) I , <br />City STZ? Zip Owner/Operator ^-OSI <br />Check all appropriate services provided: <br />■^Wastewater disposal <br />Solid waste disposal <br />yHot & Cold water for cleaning <br />' Store dry food/supplies <br />YES IK-A <br />the conditions of this agreement, or if this agreement is modified or cancelled, the <br />EHD immediately.