Laserfiche WebLink
SANAAQUIN <br />COUNTY— <br />Greotness g rows here. <br />Pa c-3440 c4U2_ <br />Environmental Health Department <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 />To be completed by APPLICANT <br />Business Name 779 CO 8/3/2/4t0 <br />Owner/Operator Name 6fi almwo ,s,q4472.2 0 <br /> <br />Lie. Plate #2-5-R 65 r <br /> <br />3 <br /> <br />Business Mailing Address 371 ‘./ k 1/TOL <br />City,513C061 StateCA Zip ?5-2-06 Bus. PL2-99623'41YiYAlt. Ph. <br />I 60U8RAD Z/i&-c -c) <br />DateS1/1112, / <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name brI MOVO itTSt /MG ?Rock erect FA# <br />Address 17/7 5 tiMod Bus. Phom0 e -29 5-4( <br />cityszcani, i1 Zip 9S:2 ti Owner/Operator aT <br />Check all appropriate services provided: <br />Ela-compartment sink <br />0/Food preparation <br /> EfrElectrical hook-ups <br />Erroilet and handwashing <br />1:2Store refrigerated food <br /> <br />Et Potable water <br />EnCvemight parking <br />11:11K/ehicle wash <br />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 condition of this agreement, or if this agreement is modi/ ed or cancelled, the <br />HD ' niediately. <br />To be completed 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 1 Stockton, California 952051 T 209 468-3420.1 F 209 464-0138 www.sjgov.orgiehd <br />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 8, <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the pe fy the EHD. Failure to notify this office may result in permit <br />revocation an'd pe les. <br />Signature <br />areWastewater disposal <br />a/Solid waste disposal <br />Er Hot & Cold water for cleaning <br />El Store dry_food/supplies <br />I, net <br />commissary owne <br />Signature Date :-CA <br />5