Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br />Date <br />J <br />Date <br />DateREHS Signature <br />| Stockton, California 9520S | T 209 468-3420) F 209 464-0138 (www.sjgov.org/ehd1868 E. Hazelton Avenui <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />___'liiirii <br />.Zipj” <br />Check all appropriate services provided: <br />O 3-compartment sink <br />O Food preparation <br /> Store refrigerated food <br />^/Overnight parking <br />Complete sections 1 and 2. If your commissary Is located outside of San Joaquin County also complete section 3. <br />'] <br />Lie. Plate# <br />EJ Electrical hook-ups <br />E5 Toilet and handwashing <br />a Potable water <br />Ek'Vehide wash <br />hereby state that the information I have provided is current, true and <br />- - — . > a — fit*. <br />operato7foils 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 r /'2\/7X /' <br />Signature K/ Till I Date-------------—------------------------ <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in Callfomia 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 />—J G\/v<x(ky»<^iiA—CJ'— Date <br />1. To be completed by APPLICANT <br />Busi ness Name X X <br />Owner/Operator Name M fAXt-A I I f y <br />Business Mailing Addressi l/L// --------------------------------- <br />City StatetA Zip /fo^pBus. Ph._ " ^^It. Ph.------------------ <br />I. UtZ/aa fcrtl/i I//, hereby state that the above information is current, true and correct to <br />the bek of my knowledge and agree to utilize my approved commissary in accordance with Callfomia 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 ptsnalties. > i . , <br />Signature '_______________________—--------------^Date__rq—I -J.-------------- <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary ttameTfflWUk LIMW.FA# ... <br />Address. J Bus Phone <br />City Zip ^*(551 Owner/OperatorTh^^'M^ <br />u/wastewater disposal <br />j^polid waste disposal <br />H Hot & Cold water for cleaning <br />Store dry food/supplies , wk_________correct^to tta best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility