Laserfiche WebLink
SAN JOAO." Environmeallealth Department <br />I <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 GLAD -J/f f papi.‘55'R/,9 Lic. Plate # 6 /3 6 S /°,Z <br />Owner/Operator Name G 6.0 15 rz.tkes C gt tiffk <br />Business Mailing Address / S)A4) GDRVtlki VERNER.- c <br />city51%0lb&J State (-Pi Zip 25-0 Bus. Plf 2 6 65 - I/Ogg Alt. Ph. r------ <br />I, CI fil)kS RE-5 , 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 penalties. <br />Signature Date /6/2 ?/7 9 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name CAM f\) CkrelOk CalT6R FA# <br />Address /7/ 7 S. wooti Sr. Bus. Phone <br />City 5706 KTO 11/4-I a Zip ?_5;2D Owner/Operator hk-r- -7-5z <br />Check all appropriate services provided: <br />02/Wastewater disposal e(3-compartment sink ga"Electrical hook-ups <br />13/Solid waste disposal 141400d preparation Er Toilet and handwashing <br />GHot & Cold water for cleaning rtr-Store refrigerated food til- Potable water <br />IMrStore dry food/supplies L1ZOvernight parking ErVehicle wash <br />I, /MT I-4,M CD <br />_ <br />, hereby state that the information I have provided is current, true and <br />correct to the 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 s I notify he EHD .rnmediately. <br />Signature Date <br /> <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 1 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd