Laserfiche WebLink
SANJOAQUIN <br />COUNTY-- <br />Greatness grows here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be com leted b APPLICANT • <br />Business Name 4 M6 u'eA 8 rg-,4 <br />Owner/Operator Name .1)(56W <br />Business Mailing Address 81-36 TREAso-kE viE <br />City .117°C/N-PAI State 44- Zip 75--2 C-2 Bus. Ph. 62 V.67kit. Ph. <br />,,OC) U4 .1tEP , 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 penaltie fl <br />Signature fe-e-d <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name FL-1--e(a FA# <br />Address t ZO Yz+ii'e -Pe Bus. Phone <br />City LOD II Zip '15 Zqi Owner/Operator <br />Er/Wastewater disposal 19/3-compartment sink 013/jlectrical hook-ups <br />014-olid waste disposal Q Food preparation <br />Mrliot & Cold water for cleaning Ia/;tore refrigerated food <br />CVS'tore dry food/supplies far6-vernight parking <br />I v•1 fl 0.4oc, , 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 shall notify the EHD immediately. <br />Signature .,./le-z•-)• <br />The commissary is located in <br />County. The above food facility meets the 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 <br />Date <br />1868 E. Hazelton Avenue i Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br /> <br />Lic. Plate # <br />Date <br />Check all appropriate services provided: <br />Toilet and handwashing <br />riK'otable water <br />GT/Vehicle wash <br />Date <br />the ENV HEALTH *urisdiction outside of San Joa