Laserfiche WebLink
(so SAN JOAQUIN <br /> <br />Environmental Health Department <br />' z,• <br /> COUNTY <br />Greatness grows here, <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 />To be completed by APPLICANT <br />Business Name Tr i" C C/\, <br />Owner/Operator Name C CL lb S c'C' C r\ <br />Business Mailing Address 2 3 L -I- <br />City 0 t StateCA-Zip 1,52-11L-Bus. PhZ DC1 )-3314 -561 Alt. Ph. <br />I, C CL r 6_9 o y ttu , 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 per it Folder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature Date ,5 /0 — 2 (4 <br />To be com leted by COMMISSARY OWNER/OPERATOR <br />Commissary Name X a CCC-Q_ Ce-4-4. 44-1 /- y FA# <br />Address 6,,,20 5 ..e.-eCkr---4-t--6"" LI, ( Bus. Phone "?'`:( VvV/ 3 5S/ <br />Zip q 5 z 5'49 Owner/Operator tkive-n/kc- ec-l-i- 57' 'NA/L.6X `3a-'`` City Leil2 i‘ <br />Check all appropriate services provided: <br />04/astewater disposal <br />r1491id waste disposal <br />ot & Cold water for cleaning <br />Store dry food/supplies <br />I , /.) , 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 owner shall notify the EHD immediately. <br />Lic. Plate # V 1(38 49 <br />04:compartment sink <br />Food preparation <br />6 Store refrigerated food <br />aKernight parking <br />O/Cectrical hook-ups <br />aVroilet and handwashing <br />Potable water <br />Ch%e-hicle wash <br />Signature Date 5 - 51 <br /> <br />3. To be completed by the ENWPIEWPWRIM 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 />REHS Signature Date <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov. <br />orgier2 &I° <br />BZ24 o