Laserfiche WebLink
SANAQQ UIN Environmental Heaith Department <br /> _ �Al —COUNTY-- <br /> COMMISSARY <br /> COUN i YCOMMISSARY 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 /> Business Name -TA CD LO C ID l Lic. Plate <br /> Owner/Operator Name V 1 e, SAL z-A <br /> Business Mailing Address _ J + C✓' • bh W es PrV 16 . <br /> City S , C - n stateC�aLZip SZ S'Bus. Ph.Z01 OJEV5I!�' Alt. Ph. <br /> hereby state that the above information is current,true and correct to <br /> the be f 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 resuft in permit <br /> revocation and penalties. c^ <br /> Signature_ ��� V�� sv p a I g LA/- Date <br /> r <br /> Commissary Name 6(-m U V 1 {1AC,�_ i <br /> Address 6OCj • ( Bus. PhoneZ <br /> City ( Zip�Owner/Operato 1� 1�rr� <br /> Check all appropriate services provided: <br /> C1,Wastewater disposal p1—compartment sink ©'ectrical hook-ups <br /> olid waste disposal 42-Iro—od preparation oilet and handwashing <br /> J2--Hot & old water for cleaning E3 St//ore refrigerated food G-Potable water <br /> e d foo suppli 0-6vernight parking 0-VeeTde wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the best of my nowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to com ly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary oall n th HD immediately. <br /> Signature z Date 2 <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 T 209 468-3420 1 F 209 4640138 1 www.sjgov.orgiehd <br />