Laserfiche WebLink
SAN_JOAQUIN 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 0 dJ Lic. Plate# 7 UX 20831. <br /> Owner/Operator Name <br /> Business Mailing Address �0 <br /> City, 07 State& Zip f 5'_;Wj6 Bus. Ph.db9- 5?t'7- 33C� AIL Ph.aW- <br /> I, 0Z hereby state that the above information is currenk.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 pe II as. <br /> Signature�A Qn/) Date /0 —/ ` �0-2/ <br /> 2. To be completed by COMMISSARY OWNEWOPERATOR <br /> Commissary Name LPL CC7 rnP ( h FA# <br /> Address Q1Cl? E rufky tk Wem Bus. Phone ` 00A - /-/ C2 L1 415 70 <br /> City /J t0 C K-kcy� Zip &15 205 Owner/Operator C\r, '. Q A cii e.-I-t <br /> Check all appropriate services provided: <br /> Wastewater disposal Er3-compartment sink EI cal hook-ups <br /> /olid waste disposal 0 Food preparation T�'tlet and handwashing <br /> Hot&Cold water for cleaning ® Sto refrigerated food �ble water <br /> e dry food//supplies ' / Overnight parking Vehicle wash <br /> 1, L / eRNq xdt---- hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledgFtions <br /> d meets the California Health&Safety Code requirements. If the food facility <br /> operator fails mply with the of this agreement, or if this agreement is modified or cancelled, the <br /> commissa owned shall no immedi tely. <br /> Sign atu Date is <br /> 3. Tobe 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 I Stockton, California 952051 T 209 468.34201 F 209 464-0138 1 www.sjgov_org/ehd <br />