Laserfiche WebLink
SAN-JOAOUIN Environmental Health Department <br /> -COU NTY— <br /> grows here, <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> [ 1 T <br /> 7 , <br /> C 0 mic P <br /> Business Nam A I <br /> ir,<lon Lic. Plate# C <br /> Owner/Operator Nam -- / -Z - - <br /> Business Mailing Address 17/ <br /> . z2d ... A4644 110 -q- <br /> 2_�tate(.4 Zip_9.S2Z&Bus. Ph. Alt. Ph. <br /> L-5-\-"(IzAa as 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 /> Signatu 1XV.01 Date 'I -2-4-23 <br /> I"Z-6614 6 14 corm <br /> _4 <br /> Commissary Name,,, 1!:;,,.A —FA# <br /> Address—BW 2121.1 A4.,`V12 EJ _ReA -Bus. Phone V 2-- Ve <br /> _S_3DOwner/Operator Sf- V.* R16mu. <br /> Check all appropriate services provided: <br /> 9(Wastewater disposal 13 3-compartment sink II/Electrical hook-ups <br /> Solid waste disposal E3 Food preparation 51 Toilet and handwashing <br /> 0 Hot& Cold water for cleaning [3 Store refrigerated food /PotableVwater <br /> 0 Store dry food/supplies 0`Overnight parking � Vehicle wash <br /> - <br /> 1, 311j�� _, hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledgefand 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 own hall no' EHD immediately. <br /> Signature Date dz 7/2-3> <br /> VbZ Zia <br /> 13 Vl�' il 6 <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above chocked 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 209 468-3420 1 F 209 464-0138 -1 www.sjgov.(:)rg/ehd <br />