Laserfiche WebLink
A <br /> Ni-JOAQUIN Environmenff;_aflJ <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 /> completed by APPLICANT <br /> Business Name L C, Lic. Plate <br /> # <br /> Owner/Operator Name E � li G <br /> Business Mailing Address.. 2j � _T L <br /> A- <br /> Cit State�j, _AZP Bus. Phb_Lq) �)S-139SAR. Ph. <br /> F I — <br /> 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 -2 V 1C Date <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary NameV N ION (Aff r)fVC <br /> 2 DUCP Ne CEN A <br /> Address KIT —Bus. Phonel( <br /> city2 -F/ 12 n- <br /> _Sjkc Zip CPIETO�Owner/Operator F—P <br /> Check all appropriate services provided: <br /> N <br /> , 'Wastewater disposal 3-compartment sink -ups <br /> Electrical hook <br /> L1Solid waste disposal U Food reparation <br /> pToilet and handwashing <br /> 11TY Hot & Cold water for cleaning Store refrigerated food Potable water <br /> Store dry food/supplies Overnight parking XX Vehicle wash <br /> I,Akifflvc TIMbo , 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 ownerall I <br /> notif)i�EHD immediately. <br /> Signature kzz��_ Date- <br /> 6 Ir <br /> [3. To be Completed-by the ENV HEALTH jurisdiction outside of San Joaquin <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 1 T 209 468-3420 1 F 209 464-0138 1 Www.sigov,org/ehd <br />