Laserfiche WebLink
SAN._ ) OA Q U I N Environmental Health Department <br />C0_lNT'r' <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 />11. To be completed <br />r,b`yt APPLICANT <br />Business Name �1....). A N N Q Wo?)) F Lic. Plate # 4LCS <br />Owner/Operator Name 9:&V )DLA [ -J <br />Business Mailing Address_ �j h C1 ``%ERD I C C4f G, T, <br />City SOCK State Zip �24 Bus. Ph. L{-V�, (, 9 2) Alt. Ph. 4 i 520 5 Qq7 <br />I, D4r\141j) 1, l /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 />r <br />Signature Date <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissar <br />Address C., <br />City <br />5A# <br />\jyh.{yLBus. Phone / <br />Owner/Operator: \ rtf d' ) t/() <br />Check all appropriate services provided <br />astewater disposal 3 -compartment sink CJ E ectrical hook-ups <br />Elso—lid waste disposal F] Fo d preparation d Toilet and handwashing <br />P,,K'ot&-Cold water for cleaning P-ttore efrigerated food Ca"'Potable--water <br />Cdry fod/upplie� vernight parking L;3 Vehicle wash <br />1, 45 hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and m ets 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 o�er s I notif e E�H�13 immediately. <br />SignatureDate_ // /ZZ <br />3. To be completed 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 <br />L <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wvrw.sjgov.org/ehd <br />