Laserfiche WebLink
SAN-40AoUIIV ErrtvlronmenW Headthi Deparr�:rr� enit, <br /> —COUNTY.-_._ <br /> f6q. F" <br /> COMMISSAR a 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. To completed by APPLICANT <br /> Business Name 4-a c MOy�s Lic. Plate# S 5 lv to �3 <br /> Owner/Operator Name_ Gne-v,-,A Son <br /> Business Mailing Address 156 YL%,ad e ; S lune/ 0V'e_' <br /> City S�-Vol_x«on StateCt-� Zip t SZo�: . Bus. Ph. 204-YS3.1021 Alt. Ph. <br /> I, , 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 JZ `h—22— <br /> r <br /> 2. be.complettid by C MMtSSARY OWNER/OPERATOR <br /> Commissary Name 4% / ' ` CIL L FA# <br /> Address, `�/h Z r fir. L'L Bus. Phon <br /> City L<' Zip ` S • G' Owner/Operator <br /> Check all appropriate services provided: <br /> j Wastewater disposal d 3-compartment sink It Electrical hook-ups <br /> Solid waste disposal ® Food preparation F�' Toilet and handwashing <br /> E� Hot & Cold water for cleaning ® Store refrigerated food p1� Potable water <br /> i' S re dry food/s/uu plies �? Overnight parking Vehicle wash <br /> I, L 42&/L 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 con itions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o er shall notify th D immediately. <br /> Signature Date /a 9 - �uo <br /> 3. To be completed by the ENV HEALTH jurisdiction 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 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />