Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> (;r;*a tnr5c prnw5 HPrp. Oop o <br /> I5ll1t/1tIG <br /> 145 S.Kilroy Rd <br /> COMMISSARY AGREEMENT 2Turlmk,CA 09-63 -2000 80 <br /> sov-63a-z000 <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 In05 aavDflr{ Lic. Plate# SS�h� 9 <br /> Owner/OperatorName�Z4� ?�Aa1 <br /> Business Mailing Address RtYrzi h'o t,,/AY 57',P Z <br /> City n ) <br /> o 0 State�Zip 5_ Bus. Ph. 7,4-t- 0-9274 Alt. Ph. 207- -f16 -1Z," <br /> I, 0 rzCA/ , hereby state that the above information is current,true and correct to <br /> the best of(24Oy knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San JoaquinC my Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the rmit holder must notify the EHD, Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date 2 t 2022_ <br /> 2. To be compleet�ted by COMMISSARY OW_NEW/tO.PERATOR <br /> Commissary Name lJ� I (/PitrO s �a Af1 l hulinn t Dma+i9 A# <br /> Address 1(15 5 • L Vo !4 ej Bus. Phone �ZJ4 3 N - Zvc� <br /> City­r,� r I D Ctt-- Zip cl S 31D Owner/Operator <br /> Check all appropriate services provided: OPP-✓z-, °✓1S w(q <br /> 0 Wastewater disposal 0'3-compartment sink 0 Electrical hook-ups <br /> Solid waste disposal 0 Food preparation U Toilet and handwashing <br /> Er Hot& Cold water for cleaning U Store refrigerated food 0 Potable water <br /> 0" Store dry food/supplies 0 Overnight parking 0'Vehicle wash <br /> I, .T r_rl,e; & i V(� _, 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 &Safely 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 own f e EHD immediately. <br /> Signature Date Y" z S - Z0 2 Z <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in &'6y\�SAcws 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 otify HD if the status of their operating permit changes. <br /> REHS Signature Date Z Z <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />