Laserfiche WebLink
e �iiN LAAIL't�) k l r(ICOG@: uh h C C ,U� � fj;� „Ur;. <br /> COMMMARY , GRCEMENT <br /> Mobile Food f=acility Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be corgi feted by APPLI."iii <br /> Business Name ycwalC Jds<(d-a 5 C,(nec e- (1,15 Lic.Plate# <br /> Owner/Operator Name V <br /> Business MaRingAddressc -! > C3r60�S�� R ✓� <br /> CityS y! i-,),, State CC4-Zip CQa(ry Bus. Ph.gd-T'`f44-aag �>_Alt. Ph. <br /> 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. C 2� <br /> Signature r Date <br /> Id <br /> . To be' Gorr cited COMMISSARY OWNER/QPE ATOR - <br /> ir <br /> Commissary Name f 2 2 �aj gzl/ J�ij f t5_ FA# <br /> Address n' �f ,� f 1 1:.i! Bus. Phone 9 , n f; �! <br /> / i <br /> City C l j ( Zip `/�� � Otamer/Operator � \r_f /, _1 lf4t— <br /> Check all appropriate services provided: <br /> F Wastewater disposal M 3-compartment sink ( 7 Electrical hook-ups <br /> Solid waste disposal Food preparaticin §,�5 Toilet and hahi Mashing <br /> Hot& Cold water for cleaning W7 Store refrigerated food Potable water <br /> N Storedry food/supplies / Mi Overnight parking <br /> Vel icla wash <br /> I, 1 cif�ULYIC-!� 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 Gude requirements: If the fp2d 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 nat the EHD im diately. <br /> Signature Date <br /> J. To be completed by the ENV HEALTH prix Tian_PA;irie of San Joaquin tee. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health 8 Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD it the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 I F 209 464LO438 I wv.n,,v.sjgcv.orgiehd <br />