Laserfiche WebLink
SANAQA UIN Environmental Health Department <br /> `. --COUNTY <br /> __- <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 Itornfeted.a APPLICANT:`_ <br /> p � 1 <br /> Business Name �� (�(.l�S lv\�y L h41 Lie.Plate# <br /> Owner/Operator Name V_A lX ULPI hf1 <br /> Business Mailing Address 0,kU S"hnShr�P S <br /> Cigt\y_G U-� State ' Zip 'l&Q Bus. Ph.QCri c�l-CJra(�Alt. Ph. <br /> V)U Ly' 4 , 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 pnd penalties. I <br /> Signatur _Or 'l_gqoat' Date Du I?:� J Do <br /> 2 To be c0rh fe_ted,b COMMISSARYOWNEWOPERATOR <br /> Commissary Name (_ A C oxp c ck r, FA# <br /> Address agco E �cy ,a uoo, Bus. Phone oew-1- 4.1 (70 - Ll S 70 <br /> City O}UC Y-AcV\ Zipp MI5 205 Owner/Operator C "z p ,A cn?,}t <br /> Check all appropriate services provided <br /> 01Wastewater disposal Er 3-compartment sink 0 EI trical hook-ups <br /> olid waste disposal p Food preparation �T list and handwashing <br /> �ot&Cold water for cleaning E3 Store refrigerated food 17 P able water <br /> El Store dry food/supplies Overnight parking Vehicle wash <br /> 1, V- � VA S hereby state that the information 1 have provided is current,true and <br /> correct to the best f 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 Date_ 2,0 <br /> 3. To be 6ompletedby the ENV HEALTH jurisdiction out§isle of,.San.;Joa cin 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. Hazeiton Avenue I Stockton,California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.orglehd <br />