Laserfiche WebLink
c <br /> -SANAOAOUIN Environmental Health Department <br /> —COUNTY— <br /> COMMISSARY <br /> OUNTY—COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections t and 2. If your commissary is located outside of San Joaquin County also complete section I <br /> 1. To be com feted by APPLICANT <br /> Business Name �kKT!11(IIM. TluS EVEN 4-T&tiL Lic.Plate# <br /> OwnerlOperatorNarle t/-Kta��Inr+ LZ6 `rQ1'tJtVVV 0-4allu LQ%t-ft •X_ <br /> Business Mailing Address 'L O 9%G f—. 'KtLA 5�— <br /> City K�N StateQ_ltiZip�S'� us. Ph.2i5i 9SS-1-1 - Alt Ph:`K�1 2 '> <br /> 1 -U:i_ hereby state that the above information is current,irue and correct to <br /> the best of m, Imowledge and agree to utilize my approved commissary in accordance with California Health E <br /> Safety Code, nd 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 andties. <br /> Signature) —LCT_ Date <br /> 2,To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name LA Cn (mac(_a (i \ FA# <br /> Address A'10W E JAmrk,% uo Bus. Phone S01 <br /> City J 1'0 C Ad_� Zip Gi5 205 Owner/Operator On"i n A to P_kf <br /> Check all appropriate services provided: <br /> x�wastewater disposal _t 3-compartment sink EI cal hook-ups <br /> ZE,"S olid waste disposal Food preparation � Toilet and handwashing <br /> Hot Iw Cold water for cleaning - Store refrigerated food Ible water <br /> /Store dry fo d/suppli s 'Overnight parking Vehicle wash <br /> ( n� ` <br /> I, � • f r l r tl _ ,hereby state that the information I have provided is current,true and <br /> correct to the best of my I owiedge,and meets the California Health&Safety Code requirements. if the food facility <br /> operator fails;to comply the conditions of this agreement or ff this agreement is modified or cancelled, the <br /> commissary owner shall y the EHD i'Yir tmediately. - n <br /> ignatrt2 Date. 0I2 Z lad <br /> be co eted 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 if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 R Hazelton Avenue I Stockton, California 952051 m 209 46t 24201 F 209,464-0138 1 wwwsigotcorglei ie <br />