Laserfiche WebLink
SANAACIUIN <br /> <br />Environmental Health Department <br />COUNTY <br />Gregtness 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 />To be completed by APPLICANT <br />Business Name <br />Owner/Operator Name RCA k`CAUlAj U Q.) V 0\ :C 0...- <br />Business Mailing Address 1,5\6 -..3K.,Kctr-\.. 71 \\Ie.) <br />CIty\r StateCis< zie6312_0 Bus. Ph( 20'21)2761(o\ (A. Alt. Ph 2°5 <br />riqers, 006. b) wo(0_, , hereby state that the above information is current, true and correct to <br />the best 0 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 ythe)permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and peVies) <br />Signature Date <br />To be/completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 1- Wciek--VT D S:%"" 6-CD FA# <br />Address 10 Bus. Phone gffl -3&6 <br />City Mt -T-6)1 Zip q5&5-4 Owner/Operator P -/?I<. C-14 ilk/A/ <br />Check all appropriate services provided: <br />Lic. Plate #1-FCS-b 3 Lk <br />X Wastewater disposal <br />)C Solid waste disposal <br />X Hot & Cold water for cleaning <br />Store dry food/supplies <br />C-JiJ <br />correct to the best of my knowl <br />operator fails to co <br />commissary own <br />Signature <br />)( 3-compartment sink <br /> <br />X Electrical hook-ups <br />..(Food preparation <br /> <br />XToilet and handwashing <br />id Store refrigerated food <br /> <br />Potable water <br />Overrgh parking <br /> <br />)( Vehicle wash <br />ereby tate that the information I have provided is current, true and <br />he California Health & Safety Code requirements. If the food facility <br />this greement, or if this agreement is modified or cancelled, the <br />Date <br /> /g <br />17/0 -0 <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 I T 209 468-3420 F 209 464-0138 I www.sjgov.orgiehd