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SAN J A UIN HeaiGtdh, 10jalglartrlflen% <br /> — -COUNTY-___. <br /> Oliv Disuibaa4 <br /> r. C"`Cu-ssaryn 145 S.Kilroy Rd <br /> COMM � , Y SREE- ENIT Turlock,CA 95390 <br /> 209fi34-2000 <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 /> Business Name �LI C)5 aas2c) Lic. Plate# ' SST i 9 <br /> Owner/Operator Name Ra-ji2.7 gdfi-� <br /> Business Mailing Address %( 2 c,✓4 y- 5 2 <br /> City nn Dt`jTfl State C ZipSSa5] Bus. Ph. -t{(6 ,1 Z7a Alt. Ph. 2-o7-1-61b `7 <br /> I, l{1 e0)� U0_C'4✓ j <br /> 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 CcAnty Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the p6rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. 11 <br /> Signature i Date � ��20 22- <br /> 2. To be completed by COMMISSARY OW_ N_ER//cOPERAT_OR <br /> Commissary Name 0 h Ut'y o s ���II i ��fi h u�i rin l r7aaw i9 sA# - - -- - — <br /> Address 1LI5 (C pfd cl Pj Bus. Phone L, 3 (L 7-06 d <br /> City T�,t r j D Cj Zip c! U 3 S o Owner/Operator PW'; �J t <br /> Check all appropriate services provided: �P .9,1S Mel <br /> O'Wastewater disposal 0'3-compartment sink � Electrical hook-ups <br /> ff Solid waste disposal M Food preparation R Toilet and handwashing <br /> Iff Hot& Cold water for cleaning a Store refrigerated food Rt Potable water <br /> 2- Store dry food/supplies 0 Overnight parking RT Vehicle wash <br /> I, .L m & I kis�2 , hereby state that the information I have provided is current,true and <br /> correctto the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> .op€rator.fails .to.comply With .the conditions .of.this agreement, .or.if.this agreement is .modified or cancelled, .the <br /> commissary own ttle EHD immediately. <br /> Signature 4 ,� Date 7 Z 7h7 2 Z. <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in St8r tS1aUS 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 otify HD If the status of their operating permit changes, ry� <br /> REHS Signature Date J Z2 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />