Laserfiche WebLink
SAN J O A Q U I N Environmental Health Department <br /> --COUNTY <br /> off�'��' Dle�t Vft <br /> J,e, r , t 1 <br /> Rd <br /> COMMISSARY AGREEMENT TYzlcck,CA95380 <br /> 209.634-2000 <br /> Mobile Food Facility Caterer <br /> Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete sect/on 3. <br /> r1. To be completed by APPLICANT // J <br /> Business Name EL /1�P riCc'�n a (�oryP5& LLC Lic. Plate# �/&7Z i( �j <br /> Owner/Operator Name_ coV r114 ren7.,de 'Z- <br /> Business Mailing Address 'Z3Z,� VeOIrl ; 0- ID-. <br /> City t"eq�t) State 1JAbp95 ' us. Ph.�2 i)3ZY 70 S It. Ph. <br /> I, I G✓ U 1 f16 hZt t7aj,7d-t%7_ , 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 l 'C l YlJ Date <br /> 2. To be completed by COMMISSARY OWNEMPERATOR --- ^---- <br /> Commissary NameU't"'o r v FA# <br /> Address /L/q s, IGI�N VXI Bus.k one ZO`) 6) -3 <br /> q- z v u n <br /> City uV IUCt zip q'5N- Owner/Operator J:v—�Anrz 1�'- k� ,;rq <br /> Check all appropriate services provided: <br /> Wastewater disposal Rf 3-compartment sink Er Electrical hook-ups <br /> Solid waste disposal Er Food preparation ECS' Toilet and handwashing <br /> X Hot& Cold water for cleaning Z Store refrigerated food ePotabie water <br /> XStore dry food/supplies r-T-Overnight parking RKVehicle wash <br /> 1, V",IAl�V G V1 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 shat ti lately. <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in ) t 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 <br /> y� status of their operating permit changes. <br /> REHS Signature_ ,Lk C &3,r- r', " / ate <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 />