Laserfiche WebLink
SAN JQQQUIN Environmental Health Department <br /> COUNTY— <br /> ' Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections J 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 (�C VQ JCA ",A 0 eG Lic. Plate# .SO�I <br /> Owner/Operator Name W C e-,LF 14 G 0 lU 7,46�Z. <br /> Business Mailing Address ) 11 TN J )AUNT V jC S-1 <br /> City 5`[UQK-f(�Aj State_(11-Zip9 S,�R 0 q Bus. Ph.20a 8(o-,c5Uq lt. Ph. <br /> I, I(A Aru A C, C 0!V 7 -2 , 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 en ies. <br /> Signature G'"`' 4 Date (-7 ) )C1 l/ <br /> _2'D')_3 <br /> 2. To be completed by COMMISSARY OWNEMPERATOR <br /> Commissary Name (J AJI Q--AU C&7t;P_/n1c, Ile( Cao%w <br /> Address 1 7 J � uAli 0 iU 5-7 Bus. Phone 120 9)_29� - QC-// <br /> City Al Zip yS,-)Q Owner/Operator 4t27 7/4}bb <br /> Check all appropriate services provided: IV D 5-7ojCA-6 c;;- <br /> 0 <br /> -'0 Wastewater disposal 0 3-compartment sink 13 Electrical hook-ups <br /> Iff Solid waste disposal 0 Food preparation 12Toilet and handwashing <br /> Of Hot& Cold water for cleaning O Store refrigerated food 13' Potable water <br /> Store dry food/supplies O Overnight parking U Vehicle wash <br /> I, ,Q/j 7 T/,Z Q h , 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 comp with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ner s notify the EHD immediately. <br /> Signature Date -7 J C1 l z 02- <br /> F3. <br /> 23. To be 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />