Laserfiche WebLink
SAN AA( ;N <br /> <br />Environmt at Health Department <br />--COUNTY <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 />To be completed by APPLICANT <br />Business Name PCCAA. 0-40 Pi LAI <br /> <br />Lic. Plate # 6N L9G- <br /> <br />Owner/Operator Name At\i3t4 L-1 r 77 4- <br />Business Mailing Address 1--) eox. <br />City c_S7oc,/.76/), State CA Zip 67s-,90g Bus. Ph;'),,Dci-S-/ e-79.0,-- Alt. Ph. <br />I, ,q A/JAL,' , 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 a <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 4--V 4'o 1 Cc (RR ()I'? <br />Address `-,s'4 Ir Bus. Phone <br />City s7-0 Zip e-t_g s' Owner/Operator <br />Check all appropriate services provided: <br />Wastewater disposal EL 3-compartment sink <br />Solid waste disposal 0 Food preparation <br />CI! Hot & Cold water for cleaning Store refrigerated food <br />in Store dry food/supplies Overnight parking <br />CA 77-v" ./-/-2 C)-) S- y' g cp. <br />\Q Electrical hook-ups <br />Nil Toilet and handwashing <br />0 Potable water <br />_z Vehicle wash <br /> , 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 _S.:7A Date <br />3 To be completed b the ENV HEALTH jurisdiction outs5A9999NoWIRM. <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 />REF'S Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sjgov.orgiehd <br />FA# <br />C N 0 ICE CREAM