Laserfiche WebLink
f K O S SM °l b-S' <br />Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date <br />DateRbHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />------COUNTY------ <br />Grer-tness grows he^e <br />1. To be completed by APPLICANT _________________ <br />Business Name6/ J/ S Lie. Plate# <br />Owner/Operator Name_ <br />Business Mailing AddressT-Cp,^ 3 ! <br /> Stat/U Zip ^n2£-'5 Sus. Alt. Ph. <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 />S ig n atu reC_____________________Date --------------- <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name v I O CloC GrdFA# T A OGO <br />Address. ?/yA Bus. Phone <br /> <br />CityyV^^ Zip Owner/Operator■ //) C/4 <br />Check all appropriate services provided^ <br /> yyastewater disposal <br /> Solid waste disposal <br />Cold water for cleaning <br />Pr Store dry food/supplies <br />L <br />3-compartment sink O^EIectrical hook-ups <br />p^Food preparation 0 Tpilet and handwashing <br />p^tbre refrigerated food P Potable water <br />0 Overnight parking Vehicle wash <br />; /tyC/-J / , 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. J <br /> Date... --------------- <br />TToTecompletedbythe^^ENVHEALTH 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 />Pl^lv^