Laserfiche WebLink
SAN 10 A Q U I N Environmental Health Department <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 y A"PPLICANT I <br /> Business Name L:,+ te� l� W \e5 'M,V1 j 6En CG��5 `L Lic. Plate# <br /> Owner/Operator Name 1(, t CGS `e0 I��i� <br /> Business Mailing Address .� '.�.� L, i bU r C L✓�, <br /> City J�DLIkOb✓1 State l�Zip �5 Bus. Ph.(2a6)2t I-294 Alt. Ph.�Aa)L2 V-ALIq <br /> I, �_AGq'ryo LLCPL , 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 perm h Ider must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date 9- �Z':;2 <br /> F2—. To be completed by COMMISSARY OWNER/OPERATOR n <br /> Commissary Name l EA G FA# OV), 4 3 a4 <br /> Address �C��2 W e� L 1'� y t:_ �/}�(> Bus. Phone 7 <br /> City� ltO6 � i,I Zip 9 j2 kO Owner/Operator 6"11 V— <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink 112f Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> ( Hot & Cold water for cleaning 10 Store refrigerated food Potable water <br /> Store dry food/supplies Overnight parking b Vehicle wash <br /> , 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 <br /> 23 <br /> 3. To be 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />