Laserfiche WebLink
<br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />. if hcre. <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 tovyvV.,), <br />Owner/Operator Name c.)ijokr-30 I\ 01-0 <br />Business Mailing Address tO 1-5 V.f 1 <br />City TM, State e-PrZip ak S37'& Bus. Ph. <br />I, *C.itf Oeprjo 12-01/A91-4° ' <br />Signature <br /> <br />Date <br /> <br />To be ompletectby COMMISSARY OWNER/OPERATOR <br />Commissary Name L 04-k c- fpp -r-c).4 Pb'l 7_,,i ,A# 00,27 4 93 <br />Address i (c:. a al HA,- VA IN) Rck Bus. Phone ,20ci - 712_— <br />City t-444 h -op Zip 9I ;"/D Owner/Operator 5fVe.. Milrly) v.. <br />Check all appropriate services provided: <br />[Z( Wastewater disposal 0 3-compartment sink ["Electrical hook-ups <br />Ei Solid waste disposal 0 Food preparation dToilet and handwashing <br />0 Hot & Cold water for cleaning 0 Store refrigerated food VPotable water <br />0 Store dry food/supplies Da/Overnight parking a/Vehicle wash <br />I, „5±4,ag...ZIAA0.5.1_ , 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 own hall no e EHD immediately. <br />Signature - Date O. 7/ 2- r--------- <br />To b completed by the ENV HEALTH jurisdiction outside of San Joaquin 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 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />1:MP411) 4 Reyno-2-0 6-01 .Ae-do e vq.),00. co r.,\, <br />Lic. Plate # ij?. 2 <br />Alt. Ph. <br />, 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 disc nued, the permit holder must notify-the EHD. Failure to notify this office may result in permit <br />revocation and oenitibs.