Laserfiche WebLink
—COUNTY— <br /> COMMISSARY <br /> --rOUNT'r---COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections f and 2, if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1: . To be:eorh letedd;ti. APPLfC/ "f <br /> Business Name 1-616�UeAid Q �Nt' Lie.Plate# J ' 2�Z�7J <br /> Owner/Operator Name Vdnj 0/a'hj,-0 JUVI✓ el?-,Jy <br /> Business Mailing Address q 0 K WCALUL c pv . <br /> CRY STUcf-/4 r State CA zip±sa D sus. Ph-L&9;'316401 Alt. Ph. 90 �wary <br /> 1, yu"'1 hereby state that the above information is curank true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance vAth California Health & <br /> Safety Code, and San Joaquin County Environmental Health Departmeni (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 /> Signatur Date 7 �a <br /> —Ta be Completedby COMMISSARY-0WNERIOPERAT-OR <br /> Commissary Name LA Ca tA� \ FA#_ <br /> Address_I':lLq7li �� yaSus. Phone _.."�^r' / Gl S 7•t'J <br /> City nn Zip e-) Owned0perator 1n. A cn -t <br /> , <br /> Check all appropriate services provided: <br /> Wastewater disposal V 3-compartment sink cal hook-ups <br /> ff'` olid waste disposal U Food preparation 2T 'let and handwashing <br /> `lot&Cold water for cleaning ® Store refrierated food L' P ble water <br /> C Sgore dr y fo®d/suppiias� Y Overnight parking " Vehicle wash <br /> 1 �0/yoy/�F Z /y /yl E hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,andm ms the California Health&Safety Code requirements. f the load facility <br /> operator fails to comply with the Gond" sof this a ent, or f this agreement is modified or cancelled, the <br /> commissaryr shall notify th a�r <br /> Signature C Cc e Date <br /> 3, To be completed by the ENV HEALTH Wsdietion ouWde of SCo. <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 permft changes. <br /> RENS Signature Date <br /> 1868 E.Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0998 1 www.sjgov org/ehd <br />