Laserfiche WebLink
Environmental! Health Department <br />Date <br />Date REHS Signature. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer - <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />) A < — ----------------------------——‘ <br />SANJOAQUIN <br />-COUNTY------ <br />• _• >i! .■ i ij < •? *v s here. <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />fQ I O Plate # <br />Electrical hook-ups <br />iM^Toilet and handwashing <br />Potable water <br />Sa^Overnight parking ©^Vehicle wash <br /> hereby state that the information I have provided is current, true and <br />if this agreement is modified or cancelled, the <br /> Date 2-b ___ <br /> |~3.. To bp/completed by the £NI^ HEALTH jurisdiction :outside..ofiSan: 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 />Wastewater disposal <br />Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />corre^X^e^besTof"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 <br />commissary owneflshall noWyttie EHD immediately. <br />Signature ''— <br />Business Name / (D / /> Z- QU plate n <br />Owner/OperatorName Q-j j ' <br />Business Mailing Address; <^3^3 ^’OYkJtQ-Y' ____________________ <br />City Q, StateCA Zip 8 jgyj-Bus. Ph. Alt. Ph.------------------------- <br />I, 73?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 pertaTttes. j /Signature Date--------------------------------------------1/2- 7/ ----------------- <br />Commissary Name L Fa# y — <br />Address_ 1^2 n 7?<4.__Bus. Phone_ <br />City t/fU- hr^>p>Zip 9 Owner/Operator <br />Check all appropriate services provided: <br />O 3-compartment sink <br /> Food preparation <br /> Store refrigerated food