Laserfiche WebLink
RECEIVED <br /> JAN 31 2024 <br /> STANISLAUS COUNTY <br /> DEPT OF ENVIRONMENTAL RESOURCES <br /> SANJOAQUIN Envaironmental Health Department <br /> _.�C <br /> 0UNTI'--_ <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 s <br /> Business Name le? % NN \. — (�, Lic. Plate# � 3 <br /> _ � 1 3 <br /> Owner/Operator Name �� <br /> -� ��A \ - <br /> Business Mailing Address � <br /> City ['l\L &ca4eState_LaZipL?5 Bus. Ph(510)q39-1122�41t. Ph. <br /> 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 di continued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and The <br /> Signature Date <br /> 2. To becom l ..ikl*"COMMISSARY. OWNER/OPERATOR,` <br /> 1 <br /> Commissary Name RA"l i ien /-ZG FA# 3 <br /> Address 1211 S. T"" S} Bus. Phone 20 q)33 S 366 3 <br /> City &Ae_5}0 Zip g5351 Owner/Operator <br /> Check all appropriate services provided: <br /> `p BGVastewater disposal iY3-compartment sink electrical hook-ups <br /> -' MSolid waste disposal Q'Food preparation GYfoilet and handwashing <br /> W'Hot& Cold water for cleaning 0 Store refrigerated food Potable water <br /> o ,� © Store dry food/supplies 0 Overnight parking Vehicle wash A- <br /> I, IV-le Zvi$ ✓ S hereby state that the information I have provided is current,true and v <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 0 113112 y <br /> 3. To be completed.by the ENV HEALTH jurisdiction outside bf San Joaquin Co. <br /> The commissary is located in WA I CL 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 /> RENS Signatur Date <br /> je4CL CG41 y 3 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />