Laserfiche WebLink
DO <br /> 9Sid <br /> SAN 10AQUIN Environmental Health Department <br /> ---C Du r-� Y <br /> ' Grrotheis q'.Q�, � <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility• Caterer <br /> afso com&te section 3- <br /> Con{n►rro sedKx+s 1 and It yoar con+rt*ssary Is kih;aiM aAaids of Son daa'Qutn�'fY <br /> tCiANT _ <br /> IM <br /> lc.Plate a <br /> Business Name" <br /> (to� <br /> ownerloperator Na e '� <br /> Bustne Marling Address <br /> C State Zip S� Bus, Ph G�' d' DliZ)Att. Ph. <br /> ! , ,hereby state that the above rnformanon is current,true and correct to <br /> It-beet of rtiy knowledge rind Ogre*Eo UlikZe my 119orcn'ed ouawnisla y in a0cwdance Omh Cabfomra me&" & <br /> Saloly Code,and San Joaquin County Enviroomontat Hoalth DepxMnertt fEHbt requrrornenis. If thri 11947 of the <br /> co-missary is dGV-"*rnred,ft ptmvt holder must notify ftre EHD Foure to ratify mrs off-ce may msutt in permit <br /> revocation and EsnaltieS <br /> a' Signature <br /> Emir I;'I Fttooby COMMISSARY OWNER/OPERATOR <br /> { v <br /> commissary HEariie "r ¢• '�" —— —-FA#— -- <br /> Address 4r zz. Sus.Ph e — <br /> cay - , zltz ate` &neooperalor� " <br /> a i Check all appropriate servom provided <br /> be Wastewater disposal 0 ?rcompadmont sink Q5 Electrical hook-ups <br /> Ej Schd waste disposal 0 Food preparation 14 Toilet and handwashing <br /> 1 Hot&gold water for cleaning O Store refru3erated food ® Potable water <br /> C e dry food! applies f' !fig Ovemight parking ttl Vehicle wash <br /> f. NrYr <br /> Z'; 7 _ hereby state that the inforrrisbvn F have provided is tumour,true and <br /> Como to the b6i ormy knovdadge. meats Ute California Health&Safety Code req tironsents. If the food taot,ty <br /> operator fades to copipy with the ns or this agree,nent, or if this agreernent IS modified or cancelled, the <br /> cvrrunis ry ohvri6r shah <br /> not <br /> t EHa Immediatef . <br /> Signaty -� j'fl(l .f.r f/I(,� c' gate ` >•�""�.� <br /> #die ENV HEALTH u s cti on outside of S <br /> The c0+►>mi3sary is located in <br /> commissary requirement$ in CaflfOrnia Health & Safety Code. The above checked sy, The seerviceve sa a available at the <br /> above camrnt scary, Please not4 EHD if the status of their operating permit changes, <br /> RENS Signature <br /> Date <br /> 1868 E.Hazetron Avenue I Stockton,GBGtomia 952051 T 209 4W34201 F 209 464-0138 1 www. <br />