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<br />SAN JOAQUIN <br />—COUNTY <br />Greatness grows her. <br />Environmental Health Department <br /> <br />-.0,r.. Oliv pi .. 8 iStribiLUGe im , <br />COMMISSARY AGREEMENT ' <br />mo <br />' 145 S. Kilroy Rd dik <br />Turlock, CA 95380 <br />Mobile Food Facility r Caterer h 209-634-2000 <br />Complete sections 1 and 2. If your commissaty is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name j log pe4/1,5e- leNtiete;q Lic. Plate # 3 <br />Owner/Operator Name IQ hon ri g t/ 5eJd 4i4 64 <br />Business Mailing Address q600 14.4; ii <br />City 54 (-t c16t Stat( Zip C/5-3./ Bus. Ph.(Zil-f )5'1,6 Ictn, Alt. Ph. <br />I, .A (1 4 4/d41 <br />Signature <br /> <br />Date - <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />L,CC- -414-y, lark Dan FA# r.„.1 Bus. Phone( zfAI )cj 7-i <br />3W City 17( cijC Zip Owner/Operator 3e-1 4-1Pei ,e‘ <br />Check all appropriate services provided: <br />.'"Wastewater disposal ,W3-compartment sink <br />Cr Solid waste disposal ? Food preparation <br />J2-r Hot & Cold water for cleaning d Store refrigerated food <br />PiStore dry food/supplies eOverni g ht parking <br />I, _1_,VOIC:6-e /Jyt /1_ , hereby state that the information I have provided <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirementE <br />operator fails to comply with the conditions of this agreement, or if this agreement is modifiec <br />commissary owner shall no • EHD immediately. <br />Signature Date <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 />Commissary Name e A 12S <br />Address I (-1) [fr(iA <br />7,i -Electrical hook-ups <br />Toilet and handwashing <br />ffrPotable water <br />re-Vehicle <br />3. To be completed by the ENV HEALTH jurisdiction outside of San, <br />The commissary is located in b-ca u-S County. The above fooe <br />commissary requirements in California Health & Safety Code. The above checked services a ui <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />r.) = <br />REHS Signature Date -1,,,o/L. 8 "! <br />w <br />< <br />1868 E. Hazelton Avenue 1 Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 v w <br />Ce <br />< <br />09-1861 cn