Laserfiche WebLink
c <br />SANJOAQUIN <br />COUNTY <br />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 <br />Owner/Operator Name Ra P R I Go <br />�1� q <br />rn�ct4su <br />_Lic- Plate #T E 1q_ <br />J 2 <br />Business Mailing Address -->3 ?y STIZLS�—T <br />City LP1i01) CI I'iStatee/' Zip Bus. Ph. Xl� ��� (6 Alt. Ph. 3-lO 377 ZZ.9y <br />1 Rot7R.t GCG InAinwo , ft , 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 />- = 0703' Zvi 2- <br />Signature_T -_ -�""� _ Date <br />2. To be completed by COMMISSARY OWNEWOPERATOR <br />Commissary Name FA# <br />Address 13 Bus. Phone 51• - C09 _`y,_ <br />j city ru r�,4ri n Zip l Owner/Operator ��>ti Ky <br />—" - 9 - <br />Check all appropriate services provided: <br />I/1 <br />�, Wastewater disposal <br />X 3 -compartment sink <br />Electrical hook-ups <br />IAC Solid waste disposal <br />�a Food preparation <br />Toilet and handwashing <br />C�H-_ot & Cold water for cleaning Store refrigerated food /iC Potable water <br />to dry fobd/supplies q Overnight parking �( Vehicle wash <br />I, I hereby state that the information I/ha_ve provided is current, true and <br />correct to the best of my k owledge, 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 EqD immediately. I f _ <br />13. To be come-Ated by the ENV HEALTH iurisdiction outside of San Joaquin Co. <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in Califo is Health & Safety Code. The above checked services are available at the <br />above commissary. Please notify FHD if )he status of their operating permit changes. G <br />REHS Signature \'� ! - i✓y�-J / t'�— Date�� O <br />868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br />