Laserfiche WebLink
FA# I/v-0 --/oci 6/ <br /> <br />Bus Phone YEj-jI /79.3 <br /> <br />SAN JOAQUIN Environmental Health Department <br />- 0 U N -F Y <br />COMMISSARY AGREEMENT <br />Mobile Food Facility •!., Caterer <br />Coniplete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name -1/e,,(624:- FL. ,+_,) Lic, Plate # v- <br />Owner/Operator Name <br /> ty -/../\-) <br />Business Mailing Address <br />City 5 -20att---State(- 02ip 61 C7 IZBus. Ph. (0//0 ceiq-4-5-714Alt. 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 Heath Department (EHD) requirements. If the use of the <br />commissary is discontinu Ahe permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and pepalties:' <br />()" - Signature — Date / 2_ /7 <br />To pe,corripleted by COMMISSARY OWNER/OPERATOR <br />Commissary Name (11 (ciLLIALUAL <br />Address acA RAkkk-ko <br />city ) Zip C-t--)--')).-b Owner/Operator 7-30JC, (-1(ta.fti <br />Check all appropriate services provided: <br />p---Wastewater disposal <br />3-compartment sink <br /> <br />Electrical hook-ups <br />El Solid waste disposal <br />Ed Food preparation <br /> El Toilet and handwashing <br />- 1;1' Hot & Cold water for cleaning <br />El Store refrigerated food <br /> <br />0 Potable water <br />0 Store dry food/supplies <br />Er Overnight parking <br /> <br />0 Vehicle wash <br />I C ( CI , 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 wr shall notify the, HD immediately. <br />Signature V't Date / 9—) )-11 <br />To be completed by the ENV HEALTIT_I jurisdiction outside of San Joaquin Co. 1 <br />The commissary is located in Citc,N;S7c41.7.5. County. The above food facility meets the <br />commissary requirements in California Health & Safety Code The above checked services are available at tne <br />above commissary. Please notify EHD if t e talus of their operating permit changes. <br />REHS Signature <br /> <br />Date I" 2 20Z5 <br />1868 E. Ftazeiton Avenue I Stockton, California 95205 1 1 209468-34201 F 209 4640138 I vAv‘v.sjgov orgiefici