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T <br />SANJOAQUIN Environmental Health Department <br />t}3h6 —COUNTY— <br />c�{>, Greatness grov;s here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility a 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' I <br />Business Name The Lemon BOX Lic. Plate # 4RZ9085 <br />Owner/Operator Name Nicole Moore <br />Business Mailing Address 708 Bradley Place Manteca CA 95337 <br />City State_Zip Bus. Ph. 510-589-6166 Alt. <br />I, Nicole Moore Raygoza , 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 penalft. <br />2. To be.con leted by COMMISSARY OWNER/OPERATOR' <br />Commissary Name Oliveros distrabution commisary Ilc. FA# <br />Address145 S. Kilroy Road Bus. Phone 209-542-0456 <br />cityTurlocl zip 95380 Owner/Operator Irma Beltan <br />Check all appropriate services provided: <br />Ig Wastewater disposal W 3 -compartment sink <br />M Solid waste disposal W Food preparation <br />® Electrical hook-ups <br />18 Toilet and handwashing <br />E Hot & Cold water for cleaning 19 Store refrigerated food M Potable water <br />W Store dry food/supplies 91 Overnight parking 0 Vehicle wal <br />1 –F-rf✓le. "& I� n , hereby state that the information I have provided it <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified <br />commissary owner shall nob EHD immediately. <br />n– Iii <br />MARY-KATECOOK <br />3. To be completed b the ENV HEALTH jurisdiction outside Senior Environmental <br />. Specialist <br />The commissary is located in `7 T ()NtSlJ:i �L County. The above food <br />commissaryrequirements in CaliforniaHealth & Safe Code. The above checked services ai <br />ENVIRONMENTAL LRESOURCES <br />q Safety Environmental Health Division <br />above commissary. Please notify EHD if the status of their operating permit changes. 3800 Cornucopia way, Sui e c <br />REHS <br />Modesto, CA 95358-9494 <br />t0� l I I aoa Direct: (209) 525-1 <br />Main: (209) 525-8700 <br />Cell: (209) 505-7388 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 w Fax (209) 525-8774 <br />STRIVING TOGETHER TO BE THE BEST <br />