Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> —Cour iT„-___ <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 /> A r <br /> Business Name \O fe r- CLS11 7cq r 4-1 C4 _ Lic. Plate#_ <br /> Owner/Operator Name S4\uacl(D(' 8 Af! r\ LoL=! - <br /> Business Mailing Address 217 11 <br /> City C__ QS StateCp Zip 01 ' 0 Bus. Ph2.o�-S3&-3015 Alt. Ph.2 9-919-- 8802 <br /> �t�yt Gt r tJ120 A 02 c-- 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 pe aities. <br /> Signatur � c � // ,Fig Date 10-ZC0-'Z(0 2-0 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Sgkda9 or V(en Aa'-Lo_ • FA# <br /> Address2S bit. 128- - Bus. Phone 'Z0C1 -538- -_10 1 SteT_ <br /> City Cgf C_S Zip C 0 OU-2Q Owner/Operator Sc<�vc�o� Q lC0(_o- - <br /> Check all appropriate services provided <br /> rd-'OVastewater disposal 0 3-compartment sink 13 Electrical hook-ups <br /> Solid waste disposal fJ Food preparation EToilet and handwashing <br /> * Hot & Cold water for cleaning 0 Store refrigerated food rE-Potable water <br /> * Storedryfood/supplies 0 Overnight parking 0 Vehicle wash <br /> I, SQr`l a o r '�-kQ(I L Z.9--,, 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 s II otify/thhee EHD immediately. <br /> Signature 7 ..\`-.t� rya Date 10 --2-G- 7-OZ-0 . <br /> I To be corri feted by the ENV HEALTH.: iarisdicfion:outside. of San Joa uin Co. <br /> The commissary is located in !E=-�iue)k-s ka u S 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 off their operating permit changes. <br /> REHSSignature? _\`w¢�X� c�Z- ClecGrri r� Date frJ-2ro-Z�Za <br /> '1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 evan;i.sjgov.org/ehd <br />