Laserfiche WebLink
n.;n..•r.................................. <br /> : <br /> ,I <br /> SAN 10 A U U I N 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 /> 1. To be completed—by <br /> APPLICANT <br /> Business Name "t('XYYQS '\V J N 11C'06A Lic. Plate# H\Ill <br /> Owner/Operator Name F✓V W I YA fft (�L?t f_�i(�Xy <br /> Business Mailing Address 4M S C�'uZ►�o -��� <br /> City LcAk State(RZip 0 4n Bus. Phj 70, 'A�7gyI�Aq- Alt. Ph. <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 /> Sionature � � Date 5�� 1 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 1`'c �� � ( r->i�rv"r��S`aY�J FA# <br /> I G � �3�-1 <br /> Address /n�n �iCtC'C��t`(L0 (�k(`� — Bus. Phon <br /> City 1 ,d Zip CIC, t---1r Owner/Operator Cr< ICI <br /> Check all appropriate services provided: <br /> Wastewater disposal 1�f__3-compartment sink .Electrical hook-ups <br /> jj Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> )6-Hot & Cold water for cleaning ❑ Store refrigerated food Potable water <br /> ❑ tore dry food/supplies ft_Overnight parking `''vehicle wash <br /> I 7 hereby state that the information I have provided is current, true and <br /> correct to the best of m 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 n i he EHD immediately. <br /> Date—as <br /> Signature <br /> 3. To be c leted b the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> County. The above food facility meets the <br /> The commissary is located in <br /> commissary requirements in California Health & Safety Code. The above checked <br /> changes <br /> above <br /> services are available at e <br /> above commissary. Please notify EHD if the status of their operatingp g <br /> Date <br /> REHS Signature <br /> Stockton, California 95205 1 T 209 468-3420 <br /> F 209 464-0138 1 www.sjgov.org/ehd <br /> 7 S68 E Hazelton Avenue � <br /> i; pS <br />