Laserfiche WebLink
revocation and penalties. <br />Signature <br />To be comp <br />To be cornpletechby. <br /> <br />Business Name iGPI(1111.\-• <br />Owner/Operator Name (.f gt-As-i 9. 50N 'I& A• <br />Business Mailing Address /(0 /-1G1 (.00\lci )e../ ?1, <br /> <br />Lic. Plate # 4\1 "Si 2150 <br /> <br />City k.A cAnke.cou State ak • Zip CAS-631- Bus. Ph. Alt. Ph.510 -01.--gq <br />I, C'-'9\1-1 0. SCOW )a-.' • , 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 Ce Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, th !der must notify-the EHD. Failure to notify this office may result in permit <br />rvoci PIA 7A FA# 00,27/93 <br />Address J co 2 al .1-1A?. s IN1 F8_ Bus. Phone ..20.1 - 71 2..- <br />City Lr44hro p Zip 9 ;3/DOwner/Operator 51-Q.-VA- Rierybrif,..- t <br />Check all appropriate services provided: <br />tt Wastewater disposal 0 3-compartment sink liElectrical hook-ups <br />d Solid waste disposal 0 Food preparation CA/Toilet and handwashing <br />0 Hot & Cold water for cleaning 0 Store refrigerated food 1;1/Potable water <br />OOvernight parking aK/ehicle wash <br /> , hereby state that the information I have provided is current, true and <br />Tor b completechbyAttie$M01 <br /> <br />nioutsideia S4RidoactuirUPo• <br /> <br />Mt <br /> <br />p <br /> <br />Commissary Name <br />0 Store dry food/supplies <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 />e EHD immediately. commissary own hall no <br />Signature A .Date 2-3 16/1 <br />Date 2110 \ 01_4 <br />!-„ S JII. <br />'PIZ 0 94 V/ 901 <br />SANdOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <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 />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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />A't ) 4 dre___‘_5