Laserfiche WebLink
trk.Wastewater disposal j2 3-compartment sink <br />et<Solid waste disposal 0 Food preparation <br />,15.Hot & Cold water for cleaning 0 Store refrigerated food <br />0 tere dry food/srlies 11,Overnight parking <br />1, Ainfi 1114 ilae-z---; 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 t mply with the conditi• s of this agreement, or if this agreement is modified or cancelled, the <br />commissary inhll notify the 5 mmediately. <br />Electrical hook-ups <br />11E(Toilet and handwashing <br />Potable water <br />Pt Vehicle wash <br />SAN JOAOUIN <br />COUNTY <br />Greotricss grow5 <br />Environmental Health Department <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 /> <br />[by APPLICANT <br /> <br />Business Name (X;t. Lic. Plate # 3-- 9' 3 3 9J <br /> <br />g (f— <br />City ---7 /-C(1474-,..„ StateM Zipqcds/ Ph.ó— 6%---,C5-4kIt. Ph. <br />1/1 LA I 7- , hereby state that the above information is current, true and correct to <br />the best bf my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San J quin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is disconti d, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalt <br />Signature <br /> 4/ <br />tiits4 tikrby COMMISSARY OWNER/OPERATOR <br />Commissary Name U-CA Co. rn tk I C0{ FA# <br />Address (2., ok t 0 • viv,,ta‘y\ci u.)C,1 /4.1 Bus. Phone 44 (a — S-70 <br />City Sk-ock4An zip 9 5-2..0 S Owner/Operator 01, rC 1/1)) <br />Check all appropriate services provided: <br />Owner/Operator Name q (ki, <br />Business Mailing Address 57e)() /// <br />/I 7 <br /> <br />Date <br /> <br />Signature <br /> <br />Date <br /> <br />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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />W 'LcE OO