Laserfiche WebLink
O�U"V <br /> SAN JOAQUIN Environmental Health Department <br /> +� COUNTY <br /> Greatness grows here, <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 completed by APPLICANT �/ _9 <br /> Business Name 0:3 r�rPl l�. Lic. Plate# `7 <br /> Owner/Operator Name 0 �A UA TO 679M CZ-1- <br /> Business Mailing Address �3 6 Z-2-O V0 -r/ L7�Z I�t <br /> City S j-C C_kl_ 61 StateC/tZip '9 Q, 06 Bus. Ph. L>?0 90 AR. Ph. <br /> I, G C9'0'L 'Lx 4. `G -, 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 tis ontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p nalties <br /> Signature f" Date f Z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name S/t C-tk70?1 �s lith 6W-y&i/-ul /I�� FA# d _77 <br /> Address 1 -13 D WE wl� �� ��� Bus. Phone ,� U � � 2 <br /> City (2,2)C /J A'l Zip Owner/Operatorelice C_�dz,�n,� LL) tr� <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal compartment sink M E ctrical hook-ups <br /> 3 Solid waste disposal E -Food preparation G Toilet and handwashing <br /> 113--Hot & Cold water for cleaning store refrigerated food C1"Potable water <br /> Store dry food/supplies El'Overnight parking 0 Vehicle wash <br /> I, , 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 owTr r notify the EHD immediately. 7 i <br /> Signature C .l.i�� �L Date �. -2 _>� 2_6 1(9 <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 Date <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209468-3420 1 F 209 464-0138 1 wvvw.sjgov.org/ehd <br />