Laserfiche WebLink
SANSJOAQUIN Environmental Health Department <br /> COUNTY <br /> �C�J <br /> ti. Greotness growl hf F,. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name L{ 6-Ta L.E VA /---LCj&:t� Lic. Plate# L'T z Q cK3 <br /> Owner/Operator Name 1�d JA I Cc- Z <br /> Business Mailing Address oZ �� M�tilO(w7i _ <br /> City S7OM /LJ State_CAZip - z0 Bus. PQOCJ-�') 7- 9� /,YAlt. Ph. <br /> I, V [L7u aA,�1/„KG , 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 - Date o/ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 1 Ig I 161AU _ ' - - FA# <br /> Address 1 17 S • U 0i0 L2 ,`fir] Bus. Phone ZO�A- Z —may- tom_ <br /> City (� j 0 AJ Zip U Owner/Operator `7 C�1ti _ //� <br /> If <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> Qj Solid waste disposal ❑ Food preparation R'Toilet and handwashing <br /> 1P Hot & Cold water for cleaning ❑ Store refrigerated food F Potable water <br /> ❑ Store dry food/supplie'ls ❑ Overnight parking g'Vehicle wash <br /> to,1, , � ' VS16 , hereby state that the information I have provided is current, true and <br /> corre t to the best of my knowled , nd meets the California Health & Safety Code requirements. If the food facility <br /> operator fails to compl ditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner oti he D immediately. _ <br /> Signature c._ Date <br /> 3. To b com feted 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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />