Laserfiche WebLink
' ,;.oP9U1N <br /> SAN J O A Q U I N Environmental Health Department <br /> - COUNTY <br /> ``,•'��, ;' Greatness rJro:,: !, , <br /> olivelis Disuivadu. <br /> ssary <br /> COMMISSARY AGREEMENTi-;� �. Co 14 ts1.s d <br /> Turlock,CA 95380 <br /> Mobile Food Facility o Caterer 209-634-2000 <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 SG/j7/rJLt �� �� Lic. Plate# �i19 5 7 <br /> Owner/Operator Name L4 lMC:,r� �� C�1 ��D ; t-1 <br /> Business Mailing Address_f 55 1 TA 1G fq Et2 Iqy r <br /> City WC's i/AMState-�A Zip C7�5.3�� Bus. Ph.b 6-96 jj 3 L/ Alt. Ph.L 16 <br /> I, `)L( 1 iyrl(„V 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 � �v1AG fl 0 C)1'\S id Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> I' i <br /> Commissary Name L I r/ �p f, o kt d-,,r,�j ���nIn i554. FA# <br /> Address I `{ ) lF > Bus. Ph�2-oc3 t1 <br /> cityTi,1 r UC — Zip Owner/Operator 71�r",-?q 6'\ <br /> Check all appropriate services provided: <br /> ® Wastewater disposal 0'3-compartment sink 0' Electrical hook-ups <br /> p' Solid waste disposal ©' Food preparation O'Toilet and handwashing <br /> Eel Hot & Cold water for cleaning 13�Store refrigerated food CY Potable water <br /> 0 Store dry food/supplies Ef Overnight parking Ol Vehicle wash <br /> I, .1,✓1/iq q & GP1 , 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 /> commissaryowner shat ett the EHD immediately. <br /> Signature Date ' Z �j — Z <br /> 3. To be completed by the ENV jHEALTH jurisdiction outside of San Joaquin Co. <br /> 154The commissary is located in � �'1 r`� I G��{ _� 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 9 12023 <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 />