Laserfiche WebLink
SAN .J O Q Q U I N Environmental Health Department <br /> ---COUNTY— <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 —fi "N\ QS (�� �S Lic. Plate# y 2 t <br /> Owner/Operator Name J�UrI N, { Q Tf161(QS <br /> Business Mailing Address tij25 SufwN 1)6Y <br /> City V DAQSn State a Zip q'53c�' Bus. Ph. C 61)l �Alt. Ph. <br /> 1, ,, —/�'or.P Ela re 5 , 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 ti, �� Date - al - LZ <br /> 2. To be c m leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name LO homit6rin /U0de540 FA# <br /> Address i.211 �5. iia S�_ Bus. Phone (260'• 38-3663 <br /> City 140de5-�o Zip 8535/ Owner/Operator Cold 1qe nmM63a N <br /> Check all appropriate services provided: <br /> [3 Wastewater disposal P 3-compartment sink Q Electrical hook-ups <br /> JA Solid waste disposal 1A Food preparation ® Toilet and handwashing <br /> ® Hot & Cold water for cleaning 7 Store refrigerated food 0 Potable water <br /> Store dry food/supplies ® Overnight parking ® Vehicle wash <br /> I, / arI Lu;.5 CcU2 , 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 immediately. <br /> Signature_ Date I I&4�i2 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in VIl C-y f 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 Signatur Date <br /> ��Sti:c�—►S��an�-e� 2�t�s�t�il�(3 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209464-0138 lwww.sjgov.org/ehd <br />