Laserfiche WebLink
9J J PV <br /> S A N J O A Q U I N Environmental Health Department <br /> Cii 07 --i.OUNTY— <br /> `�c ` Greotness 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 r <br /> Business Name LC", &r1CL Lic. Plate# I�Gi <> V�-I. <br /> Owner/Operator Name Albr'ct Ze4d 6k, <br /> S <br /> Business Mailing Address 16 /� ���� f- 4Ve <br /> CitySrOJC M StateCa Zip��` I Bus. Ph.` �i 1f>t L- 1��� Alt. Ph. <br /> I, A c1 10ed , 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 AjQ'.:1"G4 c G� Date c)17[ I t' 20 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L����, y/.�( it �� ll;�l J FA# l,1,jJ ZZ -ZL, <br /> Address � ' '� -�" Bus. Phone2 22 % /s <br /> City 6Z Zip tj( ;.��� ! Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal © 3-compartment sink Electrical hook-ups <br /> 'Solid waste disposal [3 Food preparation ,fid Toilet and handwashing <br /> Hot & Cold water for cleaning © Store refrigerated food Potable water <br /> 13 Store dry food/supplies R�Overnight parking PVehicle wash <br /> I, s�� l %'� `�; ,,�., =�: hereby state that the information I have provided is current,true and <br /> correct to the best of my kngy&dge,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 shall potify the HD lately. <br /> Signature Date <br /> - f <br /> 3. To be completed by the 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />