Laserfiche WebLink
-gfiAtiktigifitthe ENV HEALTH jurisdiction outside of San Joaquin Co. •• • <br />• <br /> <br />SAN JOAQUIN <br /> Environmental Health Department <br />COUNTY — <br />Greatness gro ,,vs <br />COMMISSARY AGREEMENT <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 />itmotoorrmtevviii'ApPLICANT <br />Business Name cc C-Vi.c. pc:\ t. Lic. Plate # 1 1-= 5 3 4 cl <br />Owner/Operator Name ccjc_ft <br />Business Mailing Address t3L1 C-7 0 ck-e r\ 0 co- k <br />City C(---(--.1"C-\c\ StateC-4 Zip C1 SLC) ci Bus. Ph. .2-0 T7UAit. Ph. <br />c‘ , 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 />rtMegaitiOWON COMMISSARY OWNER/OPERATOR <br />Commissary Name L-CA Cory\ -e.sr- C-t' (.kl CO f 0 FA# <br />aZ(Wastewater disposal *3-compartment sink /if Electrical hook-ups <br />XL Hot & Cold water for cleaning 0 Store refrigerated food CI Potable water <br />AZ(Solid waste disposal 0 Food preparation IEKToilet and handwashing <br />Address c2_ c“) 0 E . v-Ack,..., ckormi u3 Li Bus. Phone <br />City c-A-pcirt-4-1 Zip 9 s-Lo S Owner/Operator G--1 . 2-• ' 'C /v,--,,p " Pre <br />Check all all appropriate services provided: <br />ISI,Overnight parking E3._ Vehicle wash 0 Store dry food/supplies <br />1, rLLr.D 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 />Date H 21/ <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 />Signature ("R ct <br /> <br />Date 1— ) — <br /> <br />Signature <br />Date <br />REHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br /> <br />W05-2V111