Laserfiche WebLink
Environmental Health Department <br />A*’ <br />Date <br />Date <br />REHS 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 />SANJOAOUIN <br />-- COUNTY----- <br />Greatness 9fows he 'e <br />Lie. Plate# Yf <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 />B usiness Name/^^X _ <br />Owner/OperatorNamC>i O Cr-S <br />Business Mailing Address,A) ^7^ <br /> Stated ~A zjpBus. 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 />Signature zx-AE <br />2. To be completed by COMMISSARY OWNER/OPERATOR I <br /> CommissaryNam e//•7Lc<. Ar? C —(. Y)—— B A# A b. — <br />Addmss3/YA; zg. A,-A _________Bus- Phor£p^ ------- <br />City Pg / Zip ^3cio Owner/QperatorC / D <br />Check all appropriate services provided: y <br />□A/Vastewater disposal DJj-compartment sink Q/dlectrical hook-ups <br />q/Sptid waste disposal IJklCod preparation 0/Tbilet and handwashing <br />EJ^t & Cold water for cleaning O'^tore refrigerated food p^otable water <br />dHstore dry food/supplies [J^ernight parking □ Vehicle wash <br />I K/\ iYR-K/CA-A , 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. / 1 <br /> / A.» ZZWa^s— <br />YTc:EeTorn|7et^byTheTNVHEALTH 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 /> Date_ -7/2^ / 2-V_