Laserfiche WebLink
SAN 1OAQUIN Environmental Health Department <br /> COUP,ITY_— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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 -)Qba r S a�u a.d('f9t f�f�f°S Lic. Plate# <br /> Owner/Operator Namey) S CLV L1l 812 (rerrel. <br /> Business Mailing Address <br /> City TIne K401ristate C.0Wip 85165 Bus. Ph. Alt. Ph. <br /> I, 10S Cc VtIC( , hereby state that the above information is current,true and correct to <br /> the b t 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 a e (ties. <br /> Signature Date 1011610002,0 <br /> 2. To be completed bn COMMISSARY OWNER/OPERATOR <br /> CommissaryName (1+l1!tyd YIA�II 1lrtrn 5UpK� FA# <br /> Address 2_, W Ci• A%f'PCAC Y &`9 Bus. Phone 2-C-2 ct-- S' 6/ — f y46 <br /> City S bLKk,f Zip 7_0 41 Owner/Operator PZ� 5 <br /> Check all appropriate services provided: <br /> -- //Wastewater disposal U-3-compartment sink electrical hook-ups <br /> Solid waste disposal Q/Food preparation 12'�Toilet and handwashing <br /> Vf Hot & Cold water for cleaning i?'Store refrigerated food dPotable water <br /> 21�Store dry food/supplies !'-3,Overnight parking Vehicle wash <br /> 1,T�NZA46L , 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 shall notify the E mediately. <br /> Signature Date U/ � U <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 I �wAv.sjgov.org/ehd <br />