Laserfiche WebLink
W 094 4?3`-19 <br />Environmental Health Department <br />c€A-ecAsecl COMMISSARY AGREEMENT <br />Mobile Food Facility 0 Caterer Cuo(v\N, <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name -E--1 ,C__\(\ I r1 -0 <br />Owner/Operator Name —CU rs eS <br />Business Mailing Address )11 3 C 110 c I e ck u e zoct • (4,Lict • <br />City BC. StateLLZip CA. 5205 Bus. Ph. `,..09)‘4/p-Z/2/575k1t. Ph. <br />I, L o-iR oc-,5 S 7. , hereby state that the above information is current, true and correct to <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinu - • - permit holder must notify the EHD. Failure to notify this office may result in permit <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name t) k) i\) C4/(4i( Devx WFA# <br />Address 11(1 5 u o Bus. Phone 2-0 Z ilk- 5 (--//‘„ <br />City TOCK /VI Zip I s 20 Co Owner/Operator Z).5 a-7)-Kfu- 77;64/70 <br />Check all appropriate services provided: <br />Dc Wastewater disposal IS 3-compartment sink XElectrical hook-ups <br />>c Solid waste disposal -?< Food preparation N"-Toilet and handwashing <br />Hot & Cold water for cleaning )C Store refrigerated food a?..g. Potable water <br />00 Store dry food/supplies ,k Overnight parking c-Vehicle wash <br />hereby state that the information I have provided is current, true and <br />corredt to the best of my knowled e, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply w e nditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owners notify th HD immediately. <br />Signature Date / 0 /1 4.2 <br />3 T e 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 />RENS Signature Date <br />1868 E. 1-lazelton Avenue Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sjgov.org/elid <br />SAN iOAQ UN <br />COUNT\:- <br />Lic. Plate # <br />revocation and pen <br />Signature IA. / <br />-••••,'• <br />Date <br />\ e,socA-