Laserfiche WebLink
-SAN.%JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> RECEIVED <br /> E ® <br /> 7 <br /> COMMISSARY AGREEMENT AUG 11 2020 <br /> Mobile Food Facility+ Caterer ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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-bAPPLICANT`_ <br /> Business Name Uc.Plate#7LW <br /> Owner/Operator Name�� 1. �o 11,Q, t wk C\� C` <br /> Business Mailing Address 6O7r. Q �)�v �1 <br /> Cit)r ��State_MZipBus. Ph.-TQ t. Ph. <br /> I S hereby state that the above information is current,_true and correct to <br /> th est 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 Datel A�IW 6 <br /> 2 To.be:com leted b . COMMISSARY OWNERIOPERAT'OR <br /> Commissary Name L A Cm yau:c%rA� FA# <br /> Address 9goo 1`. ""AAO Uft Bus. Phone 20CI• 1:,/ (�j�I 4-15 70 <br /> City O j Uo c .krait Zip �,S d5 Owner/Operator C,,ni(J 1� �f12kt <br /> Check all appropriate services provided <br /> wastewater disposal M 3 compartment sink VT <br /> cal hook-ups <br /> $olid waste disposal O Food preparation 'let and handwashing0Hot&Cold water for cleaning 0Stow refigerated food Potable water <br /> 0 Store dry food/supplies Overnight parking Vehicle wash <br /> I, , C ot 10 tb'1 S hereby state that the information 1 have provided is current,true and <br /> correct to the best of myt}nowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comwith the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner a notify immediately. <br /> Signature Date ���©S�btdral0 <br /> 3. Tobe 66implEWd.by the ENV HEALTH jurisdiction outside'-of San:Joa uin 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 V the status of their operating permit changes. <br /> r <br /> REHS Signature Date <br /> 1868 E Hazefton Avenue I Stockton,California 952051 T 209 46834201 F 209 464-0138 1 www.sjgov.orgland <br />