Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <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 /> BusinessName (G �r, c Lic. Plate# <br /> Owner/Operator Name_ YC5cv <br /> Business Mailing Address�73p <br /> City ,�nf7° StateLA Zip f ) Bus. PhL32�)U410'2 Alt. PN2n'��CP`5 <br /> 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 penalties. <br /> Signature el Date - <br /> 2. To be com let by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L FA# o0 4 /�� <br /> Address—' -� • p Bus Phone .209 - 7j 7 <br /> City ��„_n _Zjp Cl Owner/Operator t 'e'vx <br /> Check all appropriate services provided: <br /> li(Wastewater disposal ❑ 3-compartment sink M/Electrical hook-ups <br /> ® Solid waste disposal C3 Food preparation 51Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food VPotable water <br /> ❑ Store dry food//ssuup�—plies IN/Overnight parking L1' Vehicle wash <br /> 1, 'Slk� hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledgepand meets the Califomia 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 own hall no t e EHD immediately. <br /> Signature Z 3 <br /> Date <br /> 3. To b com leted b the ENV HEALTH 'urisdiction 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_a - I .3 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 i F 209 464-0138 i www.sjgov.org/ehd <br /> '5MA$ ) 14 �aiGSS �'fl�fcC�(l�ra(,n�Fl vowo• o—" <br />