Laserfiche WebLink
SAN J Q A Q U I N Environmental Health [department <br /> --- c <br /> OJ N!TY--- <br /> 7 --- <br /> ;,- <br /> i COMMISSARY AGREEMENT <br /> Mobile Food Facility t Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed by APPLICANT.` <br /> Business Name '60 U�S C E CIl to I//���/ <br /> Lic. Plate <br /> Owner/Operator Name --- <br /> Business Mailing Address S <br /> City C State6g, pZip /�52CJ6Bus. P 2C3q) ?�'3'-1V– it. Ph. <br /> I, , hereby state that the above information is current, true and correct to <br /> the be of my knowledge atTd 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 END. Failure to notify this office may result in permit <br /> revocation and penalties. C 20 O <br /> Signature_ .���� Date <br /> 2. To be completed by COMMISSARYOWNER/OPERATOR <br /> Commissary Name C r ' (S 04Y>l /C/t– I*LFA# <br /> Address-143D IE W 63e I}VIE7 Bus. Phoned�1�9_ ��, J?/ S l Li <br /> City S Zip 9 52oS Owner/Operator l/P�/14 c –�uL PLI I 60e.11— <br /> Check <br /> Ue L.Check all appropriate services provided: / <br /> 13 Wastewater disposal 3-compartment sink 0 Electrical hook-ups <br /> a Solid waste disposal M Food preparation 13-11'ollet and handwashing <br /> 1�Hot & Cold water for cleaning O�SSt�tore refrigerated food 0 Potable water <br /> 0 tore dry food/supplies 0--overnight parking EJ Vehicle wash <br /> [, A'Z C4 4LUMMAV-' , 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 immediate[ �L/ l ZD Zd <br /> Signature t Date <br /> 3. To be completed b the' t'Y�4 !L^" Wisdiction 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 96205 1 T 209 468-3420 1 F 209 464-0138 1 w;nn.sjgov.org/ehd <br />