Laserfiche WebLink
S A N 10 A Q U I N Environmental Health Department <br /> —COUNTY- <br /> - Cracioe><, qre, : ner . <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 /> I. To be completed by APPLICANT <br /> Business Name 0SCA& ;CE CkEo�M Li3 <br /> c.Plate# S7e) 6CT3 <br /> Owner/Operator Name S 4.A Zb SSA 0301-9, <br /> Business Mailing Address 015—- E EEr <br /> KA) StateCZip ?s.2us. Ph. Z6 f^923^d+JAlt. Ph.City � 6e <br /> I, 1 <br /> yy0qk 94.4 20MEJi#4 <br /> ,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 d9rintinued,the,permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation an I ' <br /> Signature Date 5 17 --Ze <br /> 2. To e c m feted by COMMISSARY OWNER/OPERATOR <br /> Al <br /> Commissary Name Sr64kTAA4"' _!�' O§FA <br /> Address /L(3D ^ L11G�$£R fFUE Bus. Phone] D <br /> City MCkTAW Zip 9 s�Os— Owner/Operator ��4 4-ll t -rv?4/u�i� <br /> Check all appropriate services provided: <br /> 13 Wastewater disposal CFF <br /> sink C�Electrical hook-ups <br /> ® Solid waste disposal CFF od preparation DeToilet and handwashing <br /> dHot & Cold water for cleaning Store refrigerated food 0 Potable water <br /> M Store dry food/supplies a Overnight parking 0 Vehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct$} }oY°gf g ���app,d��meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to.comply with�e con7htMTof this agreement, or if this agreement is modified or cancelled, the <br /> commissary "hall;y lf,Yi-i�ig4� I mediately. <br /> Signature �.-ei/u�' �i"+�",-� ��� Date 0S 17- 2-027, <br /> 13. <br /> al 7, <br /> 3. To be completed bthe 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 l Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />