Laserfiche WebLink
t`'4UIN <br /> g SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> 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 comp <br /> leted b APPLICANT (� <br /> Business Name (f Ct. L_r�r7j Lic. Plate# <br /> Owner/Operator Name Lu n e V1Tun i Q 611r QAOo <br /> Business Mailing Address -w S�7 155i-y- 01 �'V <br /> CitIS�tate e�/Zip '752-()(Bus. Ph. Alt. Ph. <br /> I, Leon ( / n )O i(� ��iayea, 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 pens ies <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary <br /> �Name I Gr n�tiT��,�-� I✓Lcsj FA# <br /> Address WBus. Phone <br /> City SjLC>C-IC k'd—Zip G (, Owner/ era "C�e-� V-vto it.) <br /> Check all appropriate services provide�/3-compartment <br /> : <br /> EI/Wastewater disposal sink electrical hook-ups <br /> CrSolid waste disposal — Food preparation Q Toilet and handwashing <br /> d <br /> � Hot & Cold water for cleaning 112111/Store refrigerated food 3Potable water <br /> 0' <br /> cr-s-t,ore dry food/supplies _ Overnight parking O-'Poehicle wash <br /> I, �P� PU1I 11 C3 hereby state that the information I have provided is current, true and <br /> correcThe 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. <br /> Signature s 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 />