Laserfiche WebLink
Environmental Health Department <br />arov/t ’■-«=• re. <br />Lie. Plate # <br />Date 3 — 3 — £ <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />Date REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 | www.sjgov.org/ehcl <br />con \ <br />Commissary Name <br />Address 3*-l <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 />"XQ Electrical hook-ups <br />Toilet and handwashing <br />O Potable water <br /> Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />FA# <br />SAN JOAOUIN <br />------COUNTY------ <br />CsEatncss <br />n v\^ <br />Date / -■ /' <br />co <br />O ±; <br />o K> . I"! <br />om; <br /><0 > S <br />O1 < £ ^3 m n o .m $ <br />w 3 <br />2. To be completed by COMMISSARY OWNER/QPERATOR <br />f 1 C p/ esi nn <br />I rV'£P{ __________Bus. Phone <br />City S7 tlp nZ Zip Q S Owher/Operator <br />Check all appropriate services provided: <br />O Wastewater disposal 3-compartment sink <br /> Solid waste disposal O Food preparation <br /> Hot & Cold water for cleaning Store refrigerated food <br />O Store dry food/supplies Overnight parking <br />I,, 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 K) <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 />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />Business Name " ' ■ A U L T <br />Owner/Operator Name rf} lA i 7 <br />Business Mailing Address -1 ,S A? A T .3 <br />CityZ-4- f-A a f1 state c A Zip- Bus. Ph.^'- Alt. Ph.AAog <br />h _ 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 A1',.' I 7 / f’C S I 'A ^V\