Laserfiche WebLink
FA# <br />14t,ls. Phone <br />Zip Zip City 64 Owner/Operator <br />Commissary Name a`77/-?"/I-C-f4/>e <br />Address 109)1.-?__? elr/Y <br />e /-3S <br />SANJOAQUIN Env.lronmenta HeaKh Deparion(a „ <br /> <br />c!r•::iv2.=.; <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and \2. If your commissary is located outside of San Joaquin County als complete section 3. <br />1 To be complete <br /> <br />y APPLICANT <br />late# 75U34 <br />Owner/Operator Name U12LI N'101-14 &/‘ RA TAN Vi N DA '.06‘1vc\ 7,1 <br />Business Mailing Address 6-5- <br />Business Name D otZ EviAD RI-A <br />City MA NT& CP\ State CA Zip <br />U?L 1,9N <br />the best of my knowledge and agree to utili <br />Safety Code, and San Joaquin County Enviro <br />commissary is discontinued, the permit holder m <br />revocation and penalties. <br />Signature <br />951331 Bus. Ph.q2-5‘ <br /> 6,s 7 Al t. Ph. 42 7/6 06c)q- <br />ye information is cui-rerit, true and correct to <br />ssary in accordance with California Health & <br />artment (EHD) requirements. If the use of the <br />. Failure to notify this office may result in permit <br />uoc 23 i'61‘ Date <br />NE OPERATOR <br />, hereby state that the a <br />e my approved corn <br />mental Health De <br />notify the E <br />2. To be completed by COMMISSARY <br />Check all appropriate services provided: <br />astewater disposal <br /> olid waste disposal <br />LyCHot & Cold water for cleaning <br />7.1 Store dry food/supplies , <br />correct to the best of my knowl e, and meets the California Health & Safety Code reqUirements. If the food facility <br />operator fails to comply wit the conditions of this agreement, or if this agreement is m dified or cancelled, the <br />commissary owner shall no fy.the EHD imm iately. <br />Signature <br />3. To be cornpl ted by the ENV ALTH 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 />RENS Signature Date <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />4,-A 114 / ez„, , hereby state that the information I haV\e, provided is current, true and <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />Electrical hook-ups <br />Toilet and handwashing <br />'Potable water <br />*F Vehicle wash <br />Date