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° 1 SAN_JOAQUIN p <br /> Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <br /> Olivero�s//Disuiuctiv <br /> Logo ssmy <br /> COMMISSARY AGREEMENT "` �' 1453.Kilroy Rd <br /> Tu lock,CA 95380 <br /> Mobile Food Facility • Caterer ----. 2D9434-000 <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_ ELL 5 f7oo,ITY-Lt Lic. Plate# 9 y.5 -5(o q11 <br /> t <br /> Owner/Operator Name o V k 5<:�_ ( r�LQ V) <br /> Business Mailing Address � 5 a Q 0c,Y1 C) t E E+ <br /> Cityl� J State2AZip 16�J�S2Bus. Ph.(Zoi')ZZ 6- g j Alt. Ph. <br /> M <br /> I, e h l� G Ic V) , 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 Cou nvironmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, permit ho er must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penaltie <br /> Signature Date `/- Z' Z f2 <br /> 2. To be com eted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name U LUe-v-0S b ` Det &1>7iFA# <br /> Address `{5 r—1, IfDU Bus. Phone Zc7g ZEDS <br /> City TU j t7C Zip �5 ?7 S'0 Owner/Operator a r_ C, 1�lcc <br /> Check all appropriate services provided: CV9,(G`+.i o n Wt;q �✓ <br /> 0' Wastewater disposal Or 3-compartment sink 0 Electrical hook-ups <br /> [a Solid waste disposal Er Food preparation Er Toilet and handwashing <br /> 0 Hot & Cold water for cleaning 0'Store refrigerated food El'Potable water <br /> 6 Store dry food/suies Overnight parking WVehicle wash <br /> ��ci � ��ly� <br /> I, ?' , 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 n mmediately. <br /> Signature _ Date j2 Z <br /> 3. To be completed by,�th/Ii 5 le ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> 5 f <br /> The commissary is located in ` 4r) u 56, 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 Vl--}' Iv`� ��� U 2`�O Date �'Z'5 <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 />