Laserfiche WebLink
SAN: 1OAQUIN Environmental Health Department <br /> —COUNTY— <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 /,A rLO )Q p E ©AX R C R Lic. Plate#SS 5331/7 <br /> Owner/Operator Name LEOAIE6- 0P6Z-.50IeJAAjO <br /> Business Mailing Address 3.3D I E, /97" QST. 13 3,Z 'Z <br /> CityOA KIAA1D State C4Zip NO / Bus. P t67 SVy-73/3 Alt. Ph. <br /> I, 6.'66IV61r , 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 Codeand San Joa uin County Environmental Health Department (EHD) requirements. If the use of the <br /> i <br /> commissary s discontinu ,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date '2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name RN(04 !-h ER IVG I TACK CFA-Z& FA# <br /> Address-17/7 S. UAIMAl ST: Bus. Phon .2 O? <br /> City-5TOCKT6Nr C-A Zip9SZO4 - Owner/Operator f}47— FlkAoa <br /> Check all appropriate services provided: <br /> ErWastewater disposal l <br /> �/33-compartment sink M- Electrical hook-ups <br /> Solid waste disposal t(Food preparation MYToilet and handwashing <br /> V�/Hot & Cold water for cleaning Ell"Store refrigerated food 01Potable water <br /> "'Stored food/supplies <br /> E5 Overnight parking tN"Vehicle wash <br /> I t k <br /> I, � lT� Ri tliL , 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 all oti r he E D immediately. <br /> Signature O Date Z/Y z I <br /> 3. To be com leted by the ENV HEALTH jurisdiction outside of San Joaquin 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 www.sjgov.org/ehd <br />