Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> COUNIT Y-- <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 . <br /> TO 156 com letdd-b 1APPLICANT_ <br /> Business Name F 1 i S /l +C A e4j 20C] Lic. Plate# q6 9 4;� 19"3 <br /> Owner/Operator Name I Lth2 1 a f717D <br /> Business Mailing Address .17 811 AV"' <br /> City t a4rb State* Zip 032 Bus. Phx263- 30�-99,Q Lf Alt. Ph. Lf D -M 7 <br /> 1 Ii 9OLL 9.y1 (L6wI fU , hereby state that the above information is current, true and correct to <br /> the best of my knowledgd 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 Date_02- <br /> l a bla <br /> 2^ To��e com leted=b COMMISSARY OWNER%OPETOR <br /> Commissary Name �dryr.�r ' $ any ��7i>l� FA# <br /> Address 6 z -411 Bus. Phone Ze�',`72 77 Z 93-5 <br /> City Ze)0; _Zip fj Z 5/O Owner/Operator A-hgAe fry G� <br /> Check all appropriate services provided:// <br /> "-astewater disposal Gd-3-compartment sink M'EI rical hook-ups <br /> 1 'Solid waste disposalood preparation G1'f io let and handwashing <br /> U�7'Hot & Cold water for c <br /> Lleaning ���ore refrigerated food table water <br /> YStore/ dry food/supplies 0110vernight parking Qle-hicle wash <br /> Az-+e - 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 shall notify the EHD immediately. <br /> Signature 4� Date �—' Z� �z Z <br /> 7777777=,3. To be com leted b the`ENV HEALTH °urisdidbri outside of San Joa uin 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />