Laserfiche WebLink
33 3 3 <br /> �c <br /> i` COUNTY <br /> �— <br /> SAN J O A Q U I N Environmental Health Department <br /> 'L1i <br /> " l <br /> ,��� Grtotn ss 1_0,.;s -e. RECEIVED <br /> COMMISSARY AGREEMENT APR 0 5 2024 <br /> Mobile Food Facility ♦ Caterer <br /> ENVIRONMENTAL HEALTH <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County 8/9F*N t§VseCA/on 3. <br /> 1 . To be completed by APPLICANT <br /> Business Name I aco5 Al P&so Lic. Plate# (0,169 450 <br /> Owner/Operator Name Jaime 'P&L& <br /> Business Mailing Address 118e2> VV& + Lar- ' load <br /> Cit State-CAZip953014 Bus. Ph.?-(99-914f-13,$.95 Alt. Ph. <br /> I,� /z/� �_ /perf' hereby state that the above information is current, true and correct to <br /> the best of my knowl ge 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 'J <br /> Commissary Name <br /> Addres O Bus. Phone 17Jr <br /> City p Zip 3 S Owner/Operator 6 ru c; <br /> Check all appropriate services provided: <br /> 11? Wastewater disposal IR 3-compartment sink 1Z Electrical hook-ups <br /> IP Solid waste disposal 1 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning I Store refrigerated food Potable water <br /> Store dry food/supplies Or,Overnight parking I 'Vehicle wash <br /> I, M," ( 1`--Gl �ea. , 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 own r shall tify the EHD immediately. <br /> Signature Date 1�219 -asap/ <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin 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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />