Laserfiche WebLink
. . " Oc����3slo <br /> SAN lOAQUIN Department <br /> Environmental Heallir De <br /> -- <br /> CC. :T Y--- <br /> rowv. here. <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 Name7 6- �rtl('A Lic. Plate# YM L) /1 <br /> Owner/Operator Name MITv Q UE= A)A YLC-- (�UN/1-/�(.(=Z, L'/�CI Z <br /> Business Mailing Address '/,�2 /L/ . aA 17WA) AyC <br /> City 5-70CK7(I-A) State-C4-Zip q5 / -Bus. Ph.)O� -, - q92,,t Alt. Ph. <br /> 1, , 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 /> / <br /> Signature rI i/JU Date (�I / q 4?L)13 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 11 0 Aj C 67j--rjj/C 7iQUGC e%lU/,a FA# <br /> Address /7/ 7 5 UfVrd,tO S7 Bus. Phone (209) 2cl1k-5 -/lf,, <br /> City 5' LK :1a1il Zip cl S-,;�0 (, Owner/Operator 149, 7/.e4ot) <br /> Check all appropriate services provided: f U- S]-04e9G7 <br /> 21 Wastewater disposal D 3-compartment sink O Electrical hook-ups <br /> 8 Solid waste disposal D Food preparation ® Toilet and handwashing <br /> i2 Hot& Cold water for cleaning D Store refrigerated food D Potable water <br /> D Store dry food/supplies D Overnight parking ® Vehicle wash <br /> 1, /9 C/ 71441 0 , 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 /> commissaryo ner soil n tify thp,,EHD immediately. // /� <br /> Signature c Date & /6 % 1,23 <br /> 3 To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co.j <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />