Laserfiche WebLink
440 <br />SAN;JOAQUIN <br />--COUNTY-- <br />Environmental Health Department <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 1. To be completed by APPLICANT <br />Business Name�gc oS F L Yc Go \ C Lic. Plate # q U ,6 ;?47Z <br />Owner/OperatorName�Cco�..�,s�o Cexa��wv. veL <br />Business Mailing Address\4 \\ j\y S - <br />City TCa-g AA State Cf Zip 9 3� oy . Bus. Ph.(R-01) 31q -76 61 Alt. Ph.(�1) 9/y-aY& <br />I, C &JIUSU SALt�rt.ro �Q l 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 />Signatu Date <br />t,nectc all appropriate services provided: <br />10 Wastewater disposal 3 -compartment sink 1� Electrical hook-ups <br />b Solid waste disposal ❑ Food preparation 11 Toilet and handwashing . <br />Hot & Cold water for cleaning ❑ Store refrigerated food 6 Potable water <br />dry foodJs ies //�� Overnight parking 74, Vehicle wash <br />nv1v1,e <br />,4 fViy uGT Gy , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, anti meets the California Health & Safety Code requirements. If the food facility <br />operator fail mply with the coions of this agreement, or if this agreement is modified or cancelled, the <br />commissa own r shal4notify th&,RRD immediateiv.n <br />2c0 1-114-^ \ Dat, V & '-0,9 - ;;'D <br />13. To be 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 />S <br />