Laserfiche WebLink
`h"N MANN Environmental Health Department <br /> ' COUNTY <br /> r, <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 1 and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> edCS Lic.Plate#Business Namy57 5 <br /> Owner/Operator Name��I/j/1//� /viEL n� c k R UE z <br /> Business Mailing Address 3 (2 0 E AA,166RSaiv ST <br /> City 0ck7-r State C4 Zip •5a05 Bus. PhCPV t. Ph. <br /> I, M,11pif-1pl m <t1H i%G y ,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 !��ck._. 1 Date 5/2 e/2/ <br /> 2. To be com leted by COMMISSARY OWNER%OPERATOR <br /> Commissary Name 1414 rrirV 0,4IER/A1G Glick 62n11-121 -F�AI# <br /> Address(?/75 unl/oar , Bus. Phone.�Z�7l .ZgF`��f/6 <br /> CityS lf9c Dti ( tt Zip ��a2 v 6 Owner/Operator /jiQT �RR� 2 <br /> Check all appropriate services provided: <br /> El-Wastewater disposal 13'3-compartment sink 12'Electrical hook-ups <br /> E;VSolid waste disposal m"Food preparation t Toilet and handwashing <br /> GrHot&Cold water for cleaning i3'Store refrigerated food IYPotable water <br /> C'i'Store dry�food/supplies 1310vernight parking i3'Vehicle wash <br /> I, hr 1 (R h p , 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 own shall n the HD immediately. _ <br /> Signatures 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 Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit chaang/es. <br /> — LDate <br /> REHS Signature,? c TT" <br /> 1868 E. Hazelton Avenue I Stockton, Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />