Laserfiche WebLink
`- SANwlOAQUIN Environmental Health Department <br /> —COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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,compl6tedty APPLICANT <br /> Business Name�.Aa, �<L�f Lie. Plate#_V �f <br /> Owner/Operator Name,&&/'-& <br /> Business Mailing Address <br /> Citj�tP Stat Zip ?5 OBus. Ph - 9162-31!/�f Alt. Ph.S92 <br /> I, �f�)(��✓I t t/ r G 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 /�/�< �. n 7 <br /> Signature -%SG%� �5 Date / <br /> 2 Tobe .comipiletedbYCOMMISSARY-OWNER/OPERATOR <br /> Commissary Name L A CCl (VKP,:c c% rA FA# <br /> Address �Anvfk vgyQo� Bus. Phone <br /> City �U C�{c{�y� Zip 019SZo5 Owner/Operator C`n; 11 Ct 12 1 t <br /> Chec all appropriate services provideed/ _ <br /> stewater disposal �/3-compartment sink El 'cal hook-ups <br /> :Zolid waste disposal E3 Food preparation Flet and handwashing <br /> t&Cold water for cleaning © refrigerated food IIS P ble water <br /> fl/ //r dry food pp ies vemight parking Vehicle wash <br /> I�- �tli� t z hereby state that the information I have provided is current,We and n <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails omp with the conditions of this greement, or if this agreement is modified or cancelled, the <br /> commissa caner s 1 notify the EyRimrsred e . <br /> Signatur ` Date_ <br /> 3. To be corn leted:by ther ENV;HEAALTI jUt-,isdiction outside of SAn Joa,uin CO <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in Cal'ifomia 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 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />