Laserfiche WebLink
<br />, <br /> <br />To be competed by C.,‘OblivilS$ARYOWNERIOPERATOR <br />P 2 0 c)35.2_ <br />SANIJOAQUIN <br />—COUNTY - 4151 <br />Great:1 4'1c 97mrs Acre_ <br />Environmental Health Dspartnent <br />COMMISSARY AGREEMENT <br />Mobile Foot Facility Caterer <br />comPfeteSOCUMSI anaz if your caMMiSSPry is i.,7C2red 01.1tidP. Cf San ..10a4rigl7 0.41.41ri4a:Sn CaMpiete .sectbr, .5. <br />To he completed by APPLICANT <br />Bustress r tj <br />Owner/Operator Name1-'r II FLA,.(44- 194,11 (--= 2 _ <br />„ <br />Business Ming Atidress5,9 0 1ti 5 7 city_SIO_Criv,iLstate CtiZip ti.5212,5__Bus_ Ph. 1.41;j1AY.-nc t*.. Ph. ck1ff4 /44444 ref- z , horety s'Ate that the ab.ova infounation Current, trap and =rem ta the best of my knowledge and agreo to utlize rhy approved commissary naccordance with Cel5ornia Health & Safety Cade, and San Joaquin County Eriviro.nrnwial Heafth Deceit-Tient (ED) requirements. if pc-)e LZES of Me commissary Is diromr:tfluCra, the permit holder ;int fluffy the El-Tf. Failure tp notfy this office my result in permit riwooation and penalties, <br />A# <br />Address --- 11 -L) i.,.) V1:1,i,..) -[ BU3. PhOne r2i.-.C'\- iil CI .S'-- 5 44 t tel <br />CitK31 0 04610 A.) Zip q ''S-1-4,(,) (C, Owner/Operator :4Q_:.1., i reill aiii* <br />Check all appropriate services provided: <br />1;t Wastewater disposal' p' 3-compartment sin% Igi E-ectrii •nook-Gpcs <br />ja Sold waste disposal E Food preparation 2 Mkt,: end handwasning <br />Hot & Cold water for cleaning bi Store refrigerated food a Potable water <br />131 stare thy foodistippgies to Overnight parking ,f- E;OVeNcte wash , : I, 1...N,c:..., . heroPy este that, the informaEion I have provided is current, true End 001recS ,.o the best of c7). / knowledge, and meets the Califtrrila Health & Safety Code ropuiremen1.s. If thp. Faoc l'acility operator faft to comply with 1.:'2e_cg,mclIZIons of Etta agreement, or If this agreomard is modMed or carictlzed, V1E3 oarrwritissary own r shag pothryiEHD :ritinediatigy. c.....--- <br /> Date 1 I 1 °I. <br />Signahre <br />Is. To be completed by the ENV HEALTH jurisdicton -outse of :San Joaquin Co i • <br />Lic ate#fQ3 .32U.) <br />Commissary Name ) 1 <br />I lie commissary is located 'in County_ The above food facility meets the commissary raquiremerts in CaFirornia Health & Safety Co. TI 7Q abc.,vo checked services are availabzle at the above contmissary Please. notify Ei-ED If the statim 0;F-their operaEng permit. changes_ <br />REHS Sirmarfare <br />E. H22,31fon Avn oc'ezari, C2fffornis c;55 7 217.1 4-3Zii F 20.; 4Ez:-013S I 'A'swt.e4.0.N.inielld <br />-1051(03g2