Laserfiche WebLink
- SAN .: 10AQ U I iq Environmental Health Department <br /> COUNTY- <br /> Greutnes <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 /> 1 . To be <br /> completed b APPLICANT 1 u <br /> Business Name �� C6_S Gam.Os �L ���Y s Lic. Plate# �s L gZ- 7 <br /> Owner/Operator Name�A M 6 L 0 PEZ <br /> Business Mailing AddressCT <br /> City 7"RR � '>' State CA ZiBus. Ph(`z. (c28'-C*Z$S_ Alt. Ph. <br /> 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 ' continued, e permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocatio 'and pe alti ` . <br /> Signature Date <br /> �0�28' 19 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name U Al 16 / CFT(ER(P 6 -r2mC.k C EAPOR FA# <br /> Address /7/ 7 "S' . C(I io a 5 t— Bus. Phone <br /> City 5 To C_a&r, Co Zip s Owner/Operator I'M7 �� d D <br /> Check all appropriate services provided:: _./ <br /> ['Wastewater disposal tg 3-compartment sink EYElectrical hook-ups <br /> olid waste disposal GI/Food preparation ET Toilet and handwashing <br /> I9'Hot & Cold water for cleaning V3/`Store refrigerated food Potable water <br /> 03"Store dry <br /> flood/supplies ED Overnight parking ' %Vehicle wash <br /> I, #� / / ( 6n,0y 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 all noti the -immediate <br /> Signature r Date d 2 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in S fi A� TO 14& u I� 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 />