Laserfiche WebLink
• <br />SAN:JOAQUIRECEIVED _fronmental Health Department <br />--COUNTY• - <br />Grentnrcc ‘y.,rvs OCT 03 2023 <br />_ ENVI_RONMENTAL HEALTH <br />COMMISSARYIREEMENT <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 />To be completed by APPLICANT <br />Business Name-"•=i*i \Ck Lic. Plate # gAtos (0c 6 ) <br /> <br />Owner/Operator Name i„ - <br /> <br />Business Mailing Address. 6-k /Z: K <br />CityTi State l.\ Zip iuBus. Ph:LC:: L3r (4.! Alt. 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 discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature (ti=" <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Date 16 - 3-2_1 <br /> <br />Commissary Name <br />Address I II S. <br /> <br />FA# Nkc <br /> <br />Bus. Phone C.2400335 -6.3 <br /> <br />city ModesA-0 zip q5351 Owner/Operator :11 ,c, ,girke. , <br /> <br />Check all appropriate services provided: , -Ni fi tvory,.% <br /> <br />r7r Wastewater disposal Ki -compartment sink ' 12 "Electrical hook-ups <br /> <br />71'Solid waste disposal 0 Food preparation ,- <br />Hot & Cold water for cleaning Li Store refrigerated food <br />commissary owner shall notify the EHD immediately. <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 />Store dry food/supplies <br />, r tici • — . , hereby state that the information I have provided is current, true and <br />r7-"overnight parking <br />- Signature <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in -,C.M11,,,k-,-•k...;) <br />commissary requirements in California Health & Safety Code. The <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />above checked services are available at the <br />County. The above food facility meets the <br />REHS Signature Date 001 ,1—'D <br /> <br />\M„r001(fl 0€1)L:52_c7—)—Loi Gt.) <br />1868 E. Hazelton Avenue I Stockton, California 952-65 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />NosSI-tooz. <br />ErToilet and handwashing <br />CePotable water <br />EK/ehicle wash <br />Date I 0 - 23