Laserfiche WebLink
SA NA DAQ U I N Environmental Health Department <br /> --COUNTY--- <br /> ._ <br /> r Greatness grows here. <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 /> [�Jo be completed by APPLICANT <br /> Business Name � � ^.-- -- �Iale <br /> Owner/Operator Name = G!� (//� L O f7 <br /> Business Mailing Address <br /> City SXGL7U11) State <br /> OZi Bus. Ph.2i7�i 2�h-1�7 7Qalt. Ph.�_c�i- �1h'"�lOjG <br /> C?42C,6 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, e pe it older must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penal_ <br /> Signature r Date Z�l S /-ZQ.2-`4 <br /> 2. To be completed by COMMISSARY OWNEWOPERATOR <br /> Commissary NameL'.0 JU(j [Z(ICK Cut1Ij:kFA# <br /> Address I�I tWt 1U S l Bus. Phone 261- 2.q — C / L. <br /> City )/L') Cft Zip .20 - Owner/Operator 1231,eeyk 7ZZALZ <br /> Check all appropriate services provided: <br /> e�Wastewater disposal ? 3-compartment sink 'Q' Electrical hook-ups <br /> ^Solid waste disposal Pr-Tood preparation Toilet and handwashing <br /> a Hot&Cold water for cleaning *•Store refrigerated food Potable water <br /> Store dry food/supplies $Overnight parking Vehicle wash <br /> ,hereby state that the information I have provided is current,true and <br /> corr ct 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 owners otify the rrsrrkediately. <br /> Signature Date <br /> c <br /> 3, a completed by complby the ENV HEALTH jurisdiction outside of San Joaquin Co. {. ! <br /> commissary is located in _ County. The above food facility meets the <br /> The co ry ty <br /> commissary requirements in California Health-j 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 /> • A <br /> " REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton,California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd 0'j <br /> - %Z& "; . <br />