Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> Cr�_iN , r <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 o HCh ( etdev! Lic. Plate# <br /> Owner/Operator Name Q(,tYL( SUf FLVD <br /> Business Mailing Address 335 S A4"i e� Pd <br /> City_ I (arx State04 Zip 95*0 Bus. Ph. 4o8'd0/0'7-75 LAlt. Ph. <br /> 1. ( .t f.Ltt.( Sc I I"c w ,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. (� p�� <br /> Signature ' A Date <br /> `2. To be com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name rC F71_ VlV1-ei FA# / f1 <br /> Address Ib5 W 11V0'7 ff Bus. Phone 20`i- S50-91b9 oa 5-70?20q-bls <br /> �� � <br /> City �r�1'v- Zip 9S3lPtP Owner/Operator /�'i(YVicz� j'✓l�,fdv-t Calk all appropriate services provided:� � <br /> ChW/ astewater disposal B'3-compartment sink El Electrical hook-ups <br /> Ila Solid waste disposal D//Fc d preparation 9�/lpilet and handwashing <br /> D/ — <br /> Hot&Cold water for cleaning B Store refrigerated food 0 Potable water <br /> �T'store dry food/supplies OStvernight parking O Vehicle wash <br /> 1, /C/� , hereby state that the information I have provided is current,true and <br /> correct tolhe 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 hall notify the HD immediately. <br /> Signature ` Date 10/Z"] 172- <br /> 3. To be coni - sle of San Joa uin 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 952051 T 209 468-34201 F 209 464-0138 1 www slgov org/ehd <br />