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SANAAOUIN <br />—COUNTY-- <br />Greatness grows here. <br />Environmental Health Department <br /> <br />liv Distribution <br />: <br /> <br />COMMISSARY AGREEMENT Turlock, CA 95380 <br />209.634-2000 <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 />Cak Ca <br />Owner/Operator Name Po Cobtli VA 0 CO <br />Business Mailing Address -Z 2.- 0 9 u ,e_ile tQA.y.e <br />City 1-ti State 14 14 Zipq 3Y) Bus. Ph. 20q- (V/ OticaAlt. Ph. <br />()erg/4 R41-1 C-0 , 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 (END) 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 a/n enalties. <br />Signature <br />(47/6e‘i Date i 10 0 <br />i <br />Business Name Lic. Plate # 11712 i <br />2. To be completed by COMMISSARY OWNER/OPERATOR . <br />Commissary Name CAI t) -e.Ai o -3 ---0 --, -,---)4y-‘, b cif I-, Go FA# <br />Address t q 41) 4)- , r_.1 i lot/ Cal Bus. Phone (7, q) 6 3 (t- <br />City-1 in /10 CE Zip 45 '3g5 Owner/Operator <br />Check all appropriate services provided: <br />7.r Wastewater disposal <br /> 0'3-compartment sink <br /> 2r Electrical hook-ups <br />- Solid waste disposal <br /> <br />Food preparation <br />Pi Toilet and handwashing <br />.4 Hot & Cold water for cleaning Store refrigerated food <br /> <br />Potable water <br />0- Store dry food/supplies Overnight parking <br /> <br />7 Vehicle wash <br /> 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 noti immediately. <br />Signature Date <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 />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