Laserfiche WebLink
"j'a jq <br /> SAN,'JOAQUIN Environmental Health Department <br /> r _____.COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ,y. Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1' �:be dom eted by APPLICANT <br /> Business Name lVl qv j S Ct[)S CoS £mot i(p A40- I L tic. Plate# `l L2 M S S(o S <br /> Owner/Operator Name ILG'C�G1 C- [ CZ 1_"-1 Q <br /> Business Mailing Address iCDOL(k Pmie-k Lhdtn CA LlS2 3Ce <br /> City L thc-le n State 0- 1AZip gl'5223 Bus. Ph.2(A&03O13� Alt. Ph. <br /> I, aCLcU�e,( (1 o n-L-Ct le , 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 <br /> [41T be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name < CCU Mr1 r CI'l,(-� FA# <br /> Address 'Z`)(- 4cty-(AeKf► WO-V Bus. Phone 2-0Ct q(P 4(S70 <br /> City 5tycktoe) Zip Ci 5 ZD 5 Owner/Operator(,-,i- c4i 1) V- ne- 4�- <br /> Check all appropriate services provided: <br /> ,PJ" Wastewater disposal )23-compartment sink Mlectrical hook-ups <br /> p Solid waste disposal 0 Food preparation J3 Toilet and handwashing <br /> ErHot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br /> [3 Store dry food/supplies 0 Overnight parking A2 Vehicle wash <br /> 1, 4,&4 A�cC r-\C• (. , 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 owner shall notify the EHD immediately. <br /> Signature � Date <br /> 3 To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Ca <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 /> 1 1� 62(OS <br />