Laserfiche WebLink
SAN IOAQUIN Environmental Health Department <br />'—COUNTY— <br />Greatness grows here. <br />�� Ogiv D'u'sntaao <br />COMMISSARY AGREEMENTS <br />Mobile Food Facility• Caterer Tb6xm953M <br />-- <br />Complete sections 1 and 2. If your commissary is located outside or San Joaquin County also complete section 3. <br />t. To be completed by APPLICANT <br />Business Name �: Z22M T <br />Owner/Operator Name <br />Plate# `/ UN9s T7 <br />Business Mailing Address LL TR1Gf16Ell nuL— <br />city_%tq✓I-�-QCa State2AZip35337 Bus. Ph. L!/ - �7q��jt/ AIt.Ph.tol5'Ii57-4? 33q <br />1.-5U Ii YYIA✓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 />Signature S Date 3-Z9 - Z Z3 <br />Check all appropriate services provided: <br />` r pJ Wastewater disposal a 3 -compartment sink EY Electrical hook-ups <br />} p Solid waste disposal 0 Food preparation M Toilet and handwashing <br />121� Hot & Cold water for cleaning Cl Store refrigerated food Er Potable water <br />0 Store dry Bed/su plies IZrCivemight parking Er Vehicle wash <br />I, 1�V ✓✓! Q 17 /- r'qk l 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 shajLA~e EHD immediately. <br />Sinnature Date 3' Z `� - Z a Z�j <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in `7t�r✓) I� U,5 County. The above food facility meets the <br />t>;F <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 <br />2' <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 i www.sigov.org/ehd <br />