Laserfiche WebLink
f <br /> SAN 1UAQUiN Environmental Health Department <br /> 01 c o v' TLY— <br /> cqe . :ctasss 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 /> 1. To be completed by APPLICANT <br /> Business Name Re4noso5 hood True-4. LLC Lie. Plate# ro32931-3 <br /> Owner/Operator Name Ed jarclo gnome) Mora <br /> Business Mailing Address to t5 tg. N);4A 54- Aon- * 1 <br /> City State_h Zip 953 6 Bus. Ph. q2S-4ro-SyH ) Alt. Ph. <br /> I, Frluard o 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 /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName /a Comisarici juode0r) FA# <br /> Address IT\\ S. 13�' S*nrik Bus. Phone (?09)33,%-3663 <br /> City A40&5yo Zip 95351 Owner/Operator (_'old 5�nnaoe_ Cnm,";sscnd, Int. <br /> Check all appropriate services provided: <br /> [Wastewater disposal W""3-compartment sink [Electrical hook-ups <br /> [Solid waste disposal ["Food preparation 0'�Toilet and handwashing <br /> Cl/Hot& Cold water for cleaning 13"Store refrigerated food 0"'Potable water <br /> i3"Store dry food/supplies U"Overnight parking L(Vehicle wash <br /> I, /IM,rk L,,;s-r fVt- , 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 /> SignatureAWWI� Date AA02- <br /> 3. To be completed by the ENV HEALTH 'urisdiction 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. Pleasenotify EHD <br /> (1,if the status of their operating permit changes. <br /> REHS Signature y1 M>✓ Gr � -f_' 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 />