Laserfiche WebLink
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 />2. ~fe-Wcompleted by COMMISSARY OWNER/OPERATOR <br />Owner/Operator <br />□--Vehicle wash <br />Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />REHS Signature Date <br />1868 E. Hazelton Avenue [ Stockton, California 95205 | T 209 468-3420 | F 209 464-0133 | www.sjgov.org/ehd <br />^05^55^ <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 />^Electrical hook-ups <br />iToilet and handwashing <br />D Potable water <br />SAN JOAOUIN <br />C O U N T Y <br />__FA# <br />Bus. Phone <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />F 3-compartment sink <br />RLFood preparation <br />i.C-Store refrigerated food <br />□^Overnight parking <br />____________________________, 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 shaJ-n^tify the EHD immediately. <br />Sig natu re --------J—- ~ Date /]^y /2 <br />Commissary Name L/\ i'opCm'Jr C CzpnPn- <br />Address??/ 5 >yTc, <br />Zip City Zip. <br />Check all appropriate services provided: <br />CD-Wastewater disposal <br />©^olid waste disposal <br />I&-Hot & Cold water for cleaning <br />I Store dry food/supplies <br />I ' <br />Lie. Plate # <br />| 1. To be completed by APRLICANT <br />Business Name <br />Owner/Operator Name <br />Business Mailing Address <br />City Statel/Fzip f f^/Z^Bus. Ph. 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 natu re ----------- ---------------------------------------Date