Laserfiche WebLink
SANJOAQUIN Environmental Health Department <br /> " A COUNTY <br /> t9�+�oaaP Greatness grow-s 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 APPLICANT <br /> Business Name LOLL FUZ) Acid, ("UAK Lic. Plate# 6_2_?'-=), 0'-7 <br /> Owner/Operator Name &tarf4 G A 16 airno RA):e"Z <br /> Business Mailing Address Un b Az- e, c. L-n <br /> City vnf AP Stat kzip q'Q3V Bus. Ph. ' � It. Ph. <br /> N X tsMf 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 /> revocationand <br /> Signature Date IV i2.139 /;Z0Z ' <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name F� C`< fVr 01v —�51C-Z cAG dJryl FA# <br /> Address 3" IA E- Mj ryG AVN Bus. Phone <br /> City S %a c K Tow Zip C,4 Of S`a o 5 Own /er Operator -4 W <br /> 0 <br /> Check all appropriate services provided: <br /> nN � <br /> ❑ Wastewater disposal ❑ 3-compartment sink O-Electrical hook-ups M <br /> ❑ Solid waste disposal ❑ Food preparation P-Toilet and handwashing Z O <br /> ❑ Hot & Cold water for cleaning ErStore refrigerated food ❑ Potable water C7 Z0 <br /> ❑ Store dry food/supplies ®Overnight parking ❑ Vehicle wash D ;U n <br /> to D X <br /> hereby state that the information I have provided is current, true and L" C <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility p R1 <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 �, i1�,., �%f�_. 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 />