Laserfiche WebLink
SAN J O A Q U I N Environmental Health Department <br /> L-�i' .T' --COUNTY-___._ <br /> Greatness grows 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 /> A1^ �PPLICANT <br /> Business Name L-4/11 0 IAI 6t., Lic. Plate# �S2 `�`q � <br /> Owner/Operator Name 1-SG{ (eLi om et2_c) <br /> Business Mailing Address 320 C • WA` <br /> City ���� State CA Zip � � Bus. Ph. 1(P' (P q3.3i.f2S Alt. Ph. X11 cy (�N3 3 25 <br /> I,3-Sq(e-U 00c /hP12 0 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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name /�Z7t�-��- �G�u � YY FA# <br /> Address C9 2U �S Bus. Phone) Z-7,� F-3 3 2 <br /> City Zip `9 52yG Owner/Operator�A Ir J"ui t1a, x­f-'r, <br /> Check all appropriate services provided: <br /> wastewater disposal compartment sink f,El trical hook-ups <br /> solid waste disposal �ood preparation Toilet and handwashing <br /> M"'H-ot & Cold water for cleaning Store refrigerated food Potable water <br /> Store dry food/supplies Overnight parking Vehicle wash <br /> 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 dified or cancelled, the <br /> commissary owner shall notify the EHD immediately. V4 1100 "9� <br /> Signature �� L'' Ll"Z.,-- Date � ®� �� <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />