Laserfiche WebLink
—COUNTY <br />riLtpr.“2.‘.4\'' <br /> <br />(..31---.,otness crows her,i.. <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 APPLICANT <br />Business Name <br /> (//,)3,S7 tvc_ Lic. Plate # <br />Owner/Operator Name \J Cc- 01,1 c_, <br />Lict --S" Ackki <br /> <br />City /LC /I,/ ttl State (p-Zip c--1<,k2IL.Bus. Ph. 0 3/ '7 3 ci!,5t/ Alt. Ph. 11(0 5 <br /> <br />\-f S in,q1" ,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 />Signature <br /> <br /> Date C.!) .7 1 i I2 L1 <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 8 7 -CCIera/li t( C)1(//e%)- 614ea A/'FA# <br />Address pi-30. e bur-OE& A-U6 Bus. Phone (..,e0e7 - 3 s-/ <br />City i (?)C--/</OY") Zip 67 Jac Owner/Operator 162-i1 ct ClimA Pu4 J' <br />Check all appropriate services provided: <br />Wastewater disposal 113-compartment sink 1211ectrical hook-ups <br />EYSolid waste disposal Or/Food preparation EcToilet and handwashing <br />& Cold water for cleaning E'Store refrigerated food e Potable water <br />0" Store dry food/supplies 13'Overnight parking 0' Vehicle wash <br />I, Ve12--/) 014k1/1 , 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 />Business Mailing Address <br />commissary owner shall notify,tri -END immediately. <br />Signature / / Date c <br /> <br />3. To be 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 />REHS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 j T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />MZ-5 000115