Laserfiche WebLink
SAN J O A Q U I N Environmental Health Department <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 <br /> Business Name_A40T-OTITDS MEXI CA IJ05 4 CANO Lic. Plate# 14T66791 <br /> Owner/Operator Name lK115f L G&MC — CDRTE? <br /> Business Mailing Address 731 0 , REP IOttl l <br /> CitySr".' State CA Zip 9,5203 Bus. Phlao1),21n-.3736 Alt. Ph. <br /> I, , 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 and penalties. <br /> Signature Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name u N 10 A C h rG [FLIJLCV C6AITRP,FA# <br /> Address R/7 s , wlioeJ S7 Bus. Phone (zo1) -?-Y$-SyIC- <br /> 07—ChCity C 11 Zip 9SiR61 Owner/Operator /207— <br /> Check <br /> eck all appropriate services provided: <br /> wastewater disposal 1/3-compartment sink [I/Electrical hook-ups <br /> 03"Solid waste disposal Or/Food preparation Toilet and handwashing <br /> � <br /> [Hof & Cold water for cleaning Or/Store refrigerated food /Potable water <br /> ID <br /> Store dry yflood/supplies C9//Overnight parking Or Vehicle wash <br /> ( k <br /> I, ) K I cd) 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 sh II ti' EHD i ediately. q <br /> Signature Date / ,Z 2 <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 />