Laserfiche WebLink
SAN JOAQUIN <br />COUN1 Y— <br />Greatness grows here. <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 />To be completed by APPLICANT <br />Business Name KA-1\j/N id2r/), Lic. Plate # L)L/C):_2:,, <br />Owner/Operator Name Irikrai 6A5C/ <br />Business Mailing Address 6;C 7o'L,L,K) S <br />City Z----4nIA-76; State 6A- Zip 23C 'Bus. Ph ,5769 :3' 0 S-6 ' Alt. Ph.(57(') - 796,3 <br />I, T;,/,1 /4,4-• , hereby state that the above information is current, true and correct to <br />the best oh 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 per. older pust notify -the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature Date 2- - <br /> <br />To be completeg by COMMISSARY OWNER/OPERATOR <br />rvo el, PIA 7-Pi FA# oo,./ 7193 <br />I co ,20d Up,-'A INI Rci_ Bus. Phone ,,,%`/ - w2...--- 4q,g6 Address <br />City Will-op Zip 9 ;30 Owner/Operator '5FRAte— RIArW)f..e. <br />Check all appropriate services provided: <br />Wastewater disposal 0 3-compartment sink EVElectrical hook-ups <br />Solid waste disposal 0 Food preparation Ed/Toilet and handwashing <br />DHot & Cold water for cleaning 0 Store refrigerated food VPotable water <br />0 Store dry food/supplies B.:I/Overnight parking /K/ehicle wash <br />I, S f . - 4 . N I .k --- v n 5 ---- , 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 />commissaryown hall no e EHD immediately. <br />Signature Date /AZ 7/ 2- <br />To b 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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />gieviAr t) 4 ddct-ss <br />cA Irv) (A, I _ 0 al <br /> <br />Commissary Name