Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> —COUNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility* Caterer <br /> Complete sections 9 and Z If your commissary is located outside of San Joaquin County also complete section 3. <br /> 9. To be Com letedb` APPLICANT <br /> Business Name vt '��1v Lic.Plate#CJO 7 Lf 2 <br /> Owner/O erator Na e <br /> p �;)-�GiU �G/Z9/ifCA� <br /> Business Mailing Address �'L55C;¢.C,K - <br /> City. {o�lY StateL"Zip_ sr atfT Bus. Ph.,�tf- S 5'y IV Alt. Ph-"?u/- <br /> I, , hereby state that the above information is currant_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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR �- <br /> Commissary Name LA Cp raex c., (n FA# <br /> Address ri.�op 'y-- fn,fk% uo&A Bus. Phone_ a1c1• nLj (j q ?0 <br /> City U CK kcy--� Zip qS ZO Owner/Operator C,n: <br /> Check all appropriate services provided <br /> Wastewater disposal Vit'3 compartment sink 1eZ 'E;k ctrical hook-ups <br /> e8olid waste disposal Food preparation T flet and handwashing <br /> EI'Hot& Cold water for cleaning :-:1 Store refrigerated food able water <br /> re dry food/supplies U- Overnight parking Vehicle wash <br /> 1, Zrfd/ hereby state that the information I have provided is current,We and <br /> correct to the best of my knowledge,a d meets the California Health&Safety Code requirements. If the food facility <br /> operator fails comply with the itions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa owner shall notify HD immediate. <br /> Signature t:y L-4-�-�-< .Lr-'mac- vx c-c� " Date <br /> 3—To be completed 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 H Ith &Safety Code. The above checked services are available at the <br /> above commissary. Please notify the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E.Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />