Laserfiche WebLink
`rte CO <br /> S A NJ OA Q U I N Environmental Health Department <br /> —COUNTY— <br /> Ar. 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 com feted by APPLICANT <br /> Business Name �SSiE 1GE e_' JZEAM Lic. Plate# 670 <br /> Owner/Operator Name J'V) AN.TE:e T- _e'lN4 H <br /> Business Mailing Address 2? 11- H k 13Q Q p 1) � ,l' <br /> City 2�CriON State, �ZipSG1 Bus. Ph. ,yp9-420-73-41t. Ph. <br /> I, jl�crs s pet ;rv+44 , hereby state that the above information is current,true and correct to <br /> the best of n y knowledge Ad 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 100.r a Date 14 - 26 Za <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name P I CI( rv- Q ro CAG Rrv) FA# Co <br /> W n <br /> Address 3 Of I S 6' m i rf E R A V E Bus. Phone 11 v,,q 0_ & <br /> City S'%u clrr,ry, Zip C�A g 52- S Owner/ NZOperator � m <br /> Check all appropriate services provided: O �? O0 <br /> ? Z — <br /> ❑ Wastewater disposal ❑ 3-compartment sink Electrical hook-ups n <br /> comm <br /> E3 Solid waste disposal ❑ Food preparation Na Toilet and handwashing D X <br /> \� n <br /> O Hot & Cold water for cleaning \3�1 Store refrigerated food O Potable water N � m <br /> O Store dry food/supplies Y9 Overnight parking O Vehicle wash m D <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 owner shall notify the EHD immediately. <br /> SignaturDate d_!` 44--:40 %L0 <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www,sjgov.org/ehd <br />