Laserfiche WebLink
SAN4, <br /> jOAQU IN Environmental Health Department <br /> —COU NTY— <br /> cq 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 /> 1 . To be completed by <br /> APPLICANT <br /> Business Name b AN`t 4"Q WCnYz Lic. Plate#ACS 35 6 70 <br /> Owner/Operator Name ` )AV IDLA N-J <br /> Business Mailing Address 1 5 0 \JF-P))Q I C(f 4— 1 Q <br /> City :R)C.K j� State "'24� Bus. Ph. (,���> �� �i�) Alt. Ph.402, 520 6�7 <br /> I, -AM , 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 penal <br /> Signature .' ,���{�// � .9 ` Date I/ �- <br /> 2. To be completed by COMMISSARY OWN�E?R/OPERATOR <br /> Commissary Na e� t r rii �UC-7 $A# <br /> Addres ,Z fi1 Bus. F%one <br /> City Zip Owner Operator \ ) <br /> r � <br /> Check all <br /> appropriate services provided: <br /> 6astewater disposal 6 3compartment sink electrical hook-ups <br /> (3fsolid waste disposal 14 'Food preparation L `Toile_t and handwashing <br /> of --old water for cleaning P,Store frigerated food 13 Potable--water <br /> [!1� t dry food/ uppli vernight parking ('Vehicle wash <br /> I, � hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, and m ets the California Health &Safety Code requirements. If the food facility <br /> operator fails to/c�omply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner s I notif e j immediately. <br /> SignatureL 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 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />