Laserfiche WebLink
Environmental Health DeSAN�IOAQUIN partment <br /> —COUNTY— <br /> Greatness 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 - <br /> Business Name L 61AIA Y _rd L Lic.Plate#2 B QS f5T <br /> Owner/Operator Name A L O + <br /> Business Mailing Address Pg?-,S /4 02r/i OAI /k4. <br /> City,' Jr C State Zip IS2ocBus. Ph. Alt. Ph. 26? Zo�V&6 <br /> I, o �• ©y✓/�ek-1/' 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 Z s Date w-Z fl Zo <br /> 2. To Ue'com feted by COMMISSARY'OVVNER/OPERATOR .. <br /> CommissaryName_- 1kZ-'-'1CCGk FA# <br /> Address (07-0 C,. EO ' hW\i _MQ Bus. Phone(709) 'Z ZA E)33 <br /> City)-k-\ Zip Owner/Operatort�66(�!D� COft()CA <br /> Check all appropriate services provided: <br /> ip Wastewater disposal V-3-compartment sink WElectrical hook-ups <br /> PL Solid waste disposal [3 Food preparation '4 Toilet and handwashing <br /> I�L Hot & Cold water for cleaning '7i-Store refrigerated food 9L Potable water <br /> 0 Store dry food/supplies` 6Z.-Overnight parking 13 Vehicle wash <br /> 1, Qct-wAC�� �O V ) 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 noti a EHD immediately. r <br /> Signature (X�/f/ � �/�J Date UD I X77 <br /> 3. To be completed by thevENVHEALTH juri!diction 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 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 w,,"v.sjgov.org/ehd <br />