Laserfiche WebLink
S & N � U��A ' UU &� EnvironmentalU Health Department <br /> - <br /> ----COUNTY---- <br /> 6rentnc,` grnv/5 here. <br /> �*������U��x� �� ���v ����������������l� <br /> ����nmnn�nn������n� o AGREEMENT <br /> Mobile Food Facility o C8t8[GF <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name Lic. Plate# <br /> Owner/Operator NameAWIA <br /> Business Mailing Address 11�A�9 <br /> City State Bus. PhJO�' Alt. Ph. <br /> Z.4(k,-Iq , hereby state that the above information is current, true and correct to <br /> the best of my knAvled�e and agree to utilize my approved commissary in accordance with California Health & <br /> Sofah/ Coda and San Joaquin County Environmental Health Department (EHD) requirements. If the of the <br /> commissary is discontinued, the permit holder must noti D. Failure to notify this office may result in permit <br /> revocation an nal 'es. <br /> Signature J))"')�2 -Date "7 <br /> Y .: O.MMISSARY OWNER/OPERATOR <br /> Commissary Nam ' [/` F <br /> Add � -- \-�' -\ Bus. Phone �J -70 <br /> C} i 9 Owner/Operator � '7L ne�+- <br /> Checka|| mppnopriateservicenpnnvided: <br /> p� <br /> j°(VVastavvater disposal ��`3-compartment sink ^ Electrical hook-ups <br /> m3�Solidvvastedinpnna| Food preparation M^Toi|at and hondvvashing <br /> MHot & Cold water for cleaning E3 Store refrigerated food CK Potable water <br /> w� <br /> [3 M Vehicle wash <br /> IZ-R N#A47-0, , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledg nd meets the California Health&Safety Code requirements. If the food facility <br /> operator fails omp y with coftd#�Q�of th�iis agreement, or if this agreement is modified or cancelled, the <br /> Signature Date <br /> ,.'TQ1.DP,;06rnp1e"'te'd* -:-;by tha ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary iolocated 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 EHOif the status of their operating permit changes. <br /> REHS Signature Date <br /> 1888E. Hoze|tnn Avenue I Stockton, California 8S2O51 T 208408'34201 F 209464'0138 1vmww.ejgoxorg/ehd <br /> T�� -IJ <br />