Laserfiche WebLink
Se p. 16. 2022 2: 30PM No. 0369 P. 2 <br /> ic 61 SANdOAQUINa <br /> Environmental Health Department <br /> —COUNTY- <br /> 11,; <br /> OUNTY <br /> 1+,:.WO, Grroine>s grows here. <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 /> FP : a <br /> Business Name ft/�55 ��/1�('e%G'�DUS I_ic. Plate# <br /> Owner/Operator Name 44 Ice, l( m sq-/1;1a4 1 �t <br /> Business Mailing Address pAr f Peswdegv <br /> City A" State M- Zip Bus. Ph. 310" (0. �Alt. Ph. ^� <br /> I, 11s•FAt _ bmb_3�f-0owt 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�,/p�a/nalt-les. <br /> Signature ren Date <br /> s• , <br /> Commissary Name SS FA# <br /> Address /0 QS:'!, C—ff/9 L—S C hVF_Bus, Phone L.20 9) © �)-O <br /> city / Q Zip e Owne•/ perator <br /> Check all appropriate services provided: <br /> ❑ Wastewater disposal 0.3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> .Hot & Cold water for cleaning )F Store refrigerated food ❑ Potable water <br /> Store dry food/supplies OLOvernight parking ❑ Vehicle wash <br /> I,��5� S7t +V �i fy rj' _, hereby state that the information I have provided is current,true and <br /> correct to the est of my knowledg ,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 noti e-E immediateI <br /> Signat re Date <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />