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tancounty.com <br />SAN JOAQUIN <br />—COUNTY- <br />-Pos0911-1 <br />Environmental Health Department <br />Greatness grows here. <br />(fira <br />COMMISSARY AGREEMENT WNW' <br />Mobile Food Facility. Caterer <br />Oily-"a -isuiblance l <br />Co ssary <br />145 S. Kihoy Rd. <br />Turlock, CA 95380 • <br />209-634-2000 <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name rii4* ir)&225e- leNtievlq 2.0 <br />Owner/Operator Name hp,/ (44 v gad 444 <br />Business Mailing Address q6 00 tr4 [if; 1 1 0,, <br />City 54 ta ct4 , Stat"A Zip Ci‘3.49 Bus. Ph.(2c,4)91,6 - /cf 79' Alt. Ph. <br />I,him (14 <br /> Date I aD z <br />To be completed by COMMISSARY OWNER/OPERATOR <br />L,L (- <br />Commissary Name k.) €4/ riS 4.1-6-110l41-k Den5 etynnli5(4/3 FA# <br />Address I q‘--) 1,,, Bus. Phone( Ici) <br />City 1-1A, c./(jC Zip q 7-)W Owner/Operator ."--1,(evict 3e. I 41Pei <br />Check all appropriate services provided: <br />Aar Wastewater disposal ,Er 3-compartment sink Ck Electrical hook-ups <br />d Solid waste disposal ErFood preparation .Z3 Toilet and handwashing <br />J211 Hot & Cold water for cleaning d Store refrigerated food Er Potable water <br />2rStore dry food/supplies 'Overni g ht parking Er Vehicle wi <br />I, iihrliCirT)-e I4y6 K) , hereby state that the information I have provided <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 <br />Signature <br />no EHD immediately. <br />Lic. Plate # 3 <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 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 penalties. <br />Signature <br />Date ' 2 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San <br />The commissary is located in blick ol LA us County. The above food <br />commissary requirements in California Health & Safety Code. The above checked services <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature jC(Nt..._•/•••._ ••-•\t\-F-9-* Q):41—"' Date 11,1\ <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I u