Laserfiche WebLink
Q�ovik c <br /> S KJ O A Q U I N Environmental Health Department <br /> � COUNTY <br /> C,pP?�tir 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 APPLICANT <br /> Business Name /A X G,c----,. i(L(yPs LA M Lic. Plate# 6a VO 7qT7 <br /> Owner/Operator Name 1 0 IR CzE T"F% L E Z C11Z-MAf/ <br /> Business Mailing Address )4';3 t C Atx0 Y A— <br /> City Sk0L}Me)' \ State—Zip Bus. Ph. meq_S j3--jq5:-Aft. Plus — /(�1 <br /> I lame IJ-21 te hereby state that the above information is current,true and correct to <br /> the best df 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 ties. <br /> Signatur Date a E— Q Q.—D CL <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name �I��ll aV q,) r M FA# <br /> Address 3_ //'Z (1, rr,j�GF_T� �� Bus. Phone a cl - C t fir'' /'7 t l �J <br /> City <76 C4 %off CL4 Zip Ot SDoS Owner/Operator ,S'471 '/acI '-rV 4 1) S'04.3 <br /> Check all appropriate services provided: <br /> p Wastewater disposal O 3-compartment sink Electrical hook-ups <br /> p Solid waste disposal ® Food preparation Toilet and handwashing <br /> CI Hot & Cold water for cleaning�� Store refrigerated food ® Potable water <br /> ® Store dry food/supplies Overnight parking Q 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 meets the California Health&Safety Code requirements. If the food facilit <br /> � <br /> operator fails to comply with the conditions of this agreement, or if this agreement iWeWr(p tGF, REAM <br /> commissary owner shall notify the EHD immediately. 3412 E. MINER AVE. <br /> Signature l , c_, ^4 Date 'DL— `SPIMJ' , CA 95206- <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 />