Laserfiche WebLink
SAN J O A Q U I N Environmental Health Department <br /> -----r OU N TY ---- RECEIVED <br /> COMMISSARY AGREEMENT JUN 0 5 2019 <br /> Mobile Food Facility Caterer ENVIRONNIENTAL HEAL;I'H <br /> DEPARTMENT <br /> Complete sections 9 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 F j(1F=D i7�r'Z 0,/—t ' Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address r G, `t <br /> City ��?(? Vii_,^ Statee`'gP Zip ` `� ='`C Bus. Ph- Alt. Ph. <br /> I, � 6` i � i° �%" 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 peralt� <br /> Signature <br /> i <br /> / � _,� Date G, <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name , s (�, lr - � FA# f <br /> Address =; t Bus. Phone <br /> City ,�i-_o-��: Zip � /-�� Owner/Operator�J'JJV06.l`j Cit1s'°l"k,j <br /> Check all appropriate services provided- <br /> [3 astewater disposal II/Toilet-compartment sink Electrical hook-ups <br /> �olid waste disposal C ood preparation and handwashing <br /> ot & Cold water for cleaning r Store refrigerated food ❑ Potable water <br /> tore dry food/supplies ❑ Overnight parking ❑ Vehicle wash <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 <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled. the <br /> commissary owner slhall noti '.the VIII it Fn)ediately. <br /> Signature ' � / Date 10 <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 j F 209 464-0138 1 wwvd.sjgov.org/ehd <br />