Laserfiche WebLink
a SAN <br /> OA N <br /> _ ` 'N��` Environmental Health Departmc <br /> "irPotraeza grows hcre <br /> COMMISSARY AGREEMENT <br /> 1ptete section's f Mobile Fggd Facility o Caterer <br /> and 2. If your carnmrs;; <br /> To <br /> �� _ ary is located oulside of San Joaquin County also campler <br /> be corn leted APP � <br /> ,ss Name LlCANT'(�Y�� <br /> _r/Operator Name Lic.Plate <br /> -Business Mailing Address 3C. <br /> City �{ �C - <br /> 1, U —r�State�Zip r 3 Bus.Ph. 20r1 <br /> � -�-�L -S 6 Aft. Ph- <br /> the best of my kn, me a —•hereby state that the above information is current,true and coi <br /> Safe 9 and agree to utilize my approved commissary in accordance with California Healin a <br /> Safety Code, and San Jgaqui County Environmental Health Department(EHD)requirements. If the use of the <br /> :Signatur <br /> mmissary is disc a permit holder must notify the EHD. Failure to notify this office may result in permit <br /> ocation and I <br /> e <br /> — Date I <br /> :r I e cam Ieted b COMMISSARY OWNER/OPERATOR <br /> ' �_ _ <br /> Commissary Name i W) `` o t �,� � <br /> y 1� �FA <br /> Address rr I(�rV Bus. Phorte_2(]6)ZCL�-- 5 L l `>U <br /> City����,�7U +V zip 5 � t?wnerlOpera[or '� 5y y�e�Q 7J 1?r�C7 <br /> Check all appropriate services provided: <br /> [r Wastewater disposal 9 3-compartment sink E3 Electrical hook-ups <br /> K Solid waste disposal 9 Food preparation IS Toilet and handwashing <br /> at Hot& Cold water for cleaning ❑ Store refrigerated food M Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking CF Vehicle wash } <br /> t' hereby state that the information i have provided is current,true and <br /> I' J e,and meets the Califomia Health&Safety Code requirements. if the food facil- <br /> correct the best of my icnowledg <br /> i ie conditions of this agreement, or if this agreement is modified or cancelled, the <br /> operator fails to <br /> commissary a r i he EHD immediately. ��Z Dale l <br /> Signature <br /> IP[i�l 1 Y: <br /> HEALTH "urisdiction outside of San Jo , <br /> Feted b the ENV HE <br /> a' <br /> I•AIr•k��!. ,.: DIY- 4 <br /> County. The above food facility meets the <br /> The commissary is located in 1 <br /> commissary requirements in Califomia Health & Safety Code. The above checked services are available at the.- ;; <br /> lease notify EHD if the status of their operating permit changes. <br /> above commissary- P <br /> Date ' h° <br /> ." <br /> REI-iS Signature ° <br /> Stockton, 95205 1 T 209 465-:�420 i F 209 4ort-0138 f www.slgov,org/eh <br /> ,C r 1 <br /> r8b8 E. Hazelton Avenue I J <br />