Laserfiche WebLink
SAN J OAQ U I N Environmental Health Department <br /> -COUNTY -- <br /> Greatn?:,: grown -he,-. <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 L h I C&� Toc o 5 C&c Lic. Plate# <br /> Owner/Operator Name Jose on ip d 6G rC i a (Venegja5 <br /> Business Mailing Address j2 13 nor clC Ua <br /> 17 <br /> Cit y0on'e54--n State6,4 Zip x/5355 Bus. Ph. �'� va)W6 - iL9 Alt. Ph. 86u-6Z6j <br /> I, Soyati wQ 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�/1/� <br /> 9' Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 2a 61Umi5c-ris Modesj-o FA# <br /> Address ?ail c5. Sf Bus. Phone (g0L 3 6 6 3 <br /> City pode-5 _Zip 5351 Owner/Operator (-,Old 5toy^c a <vh���sSG��I�,lam• <br /> Check all appropriate services provided: <br /> Wastewater disposal d'3-compartment sink ff-Electrical hook-ups <br /> [,Solid waste disposal Food preparation O"'Toilet and handwashing <br /> !'Hot & Cold water for cleaning [�Store refrigerated food [3/Potable water <br /> Store dry food/supplies Overnight parking ® Vehicle wash <br /> I, Burk Lu i.5 (IrUZ I 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 owner shall notify the EHD immediately. <br /> Signature Date �/z��3 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in Q4--�'�'I k u-,(- County. The above food facility meets the <br /> commissary requirements in California Heal Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if th sta s of their operating permit changes. <br /> REHS Signature ✓ Date 1 z� <br /> L.,� I�k,` (76�� 7-5-- `7 p <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 />