Laserfiche WebLink
G rz , <br /> <br />`0A_I" <br /> <br />-Electrical hook-ups <br />15-Toilet and handwashing <br />ti Potable water <br />-19, Vehicle wash <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY — <br />Greatness arow <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 />Owner/Operator Name <br />Businer Maili <br />City J14 State64- Zip '157 :2 9- Bus. ph.ar--„244/ - 7P--(Alt. Ph. <br />I, AO rux--f-ii ay, Maldo V aCIU , 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 pe <br />1 '-ikiiihf y APPLICANT <br />---. i) e! ,2 <br />Business Name n....tv .64,69-ii de 3,1...'7t -e--- Lic. Plate # <br />14" (--i (-44 /alejtc-vi e--tei-6--- <br />Addres‘ /Z, A. `--"fizi ,27td/k <br />1 <br />Date <br />Signature <br />by COMMISSARY OWNER/OPERATOR <br />Commissary Name Lci, co merc, Ccrp <br />Address 9--c100 c'"1,..., wo.k.i Bus. Ph <br />City 5 VOLA-Votrir Zip CiS Lo 5 Owner/Operator <br />Check all appropriate services provided: <br />34 Wastewater disposal <br /> 4-0 3-compartment sink <br />cit Solid waste disposal <br /> 0 Food preparation <br />,Er\Hot & Cold water for cleaning <br /> 0 Store refrigerated food <br />1:1?Styre dry food upplies <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br /> , hereby state that the information I have provided is current, true and <br />itions of this agreement, or if this agreement is modified or cancelled, the <br />--tfOvernight parking <br />Date <br />L3L-TOVO;10001010100byT-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. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />CDO <br />one <br />FA# <br />zoci 462 4- 4C -70 <br />operator fails to comply with the <br />commissary ))er shall notif to .."-HD immediately. zi.vg <br />' <br />Signature ')c-n.-<-