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Tates- 6=2 e4-0 P) Oci/g9/ <br />Environmental Health Department <br />- . <br />.-- Greatness grows here. <br />COMMISSARY AGREEMEN <br />Mobile Food Facility Caterer <br />Olive DisuthclThi. <br />CO iv+ sary <br />145 ey 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 />1. To be completed by APPLICANT <br />Business Name OLCO& 1 o eco &D ot Lic. Plate # 1-11-12_39LIQ <br />Owner/Operator Name EPO'it9V1 3 1 bel I T2. <br />Business Mailing Address 35 Lem m 0 yAs <br />City aive.cb(AOL State Ca Zip ct536-7 Bus. Ph.000 -7(0 5-3-7 61 (0 Alt. Ph. <br />I, hereby state that the above information is current, true and correct to <br />the best of-tny 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 />SANJOAQUIN <br />COUNTY <br />Signature Date 10 9 7-0 Z <br />j 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 0I1€5 r 1141)1A 4-1-VI el:2°1°11'51U /12/P <br />Address J Lj5 5 . Ict li c7 L Bus. Phone (2-q) L.3 ziryz, cD <br />City -1'4 1(1C C.A6- Zip q6 3? Owner/Operator /-711/-0..r-? <br />Check all appropriate services provided: <br />el Wastewater disposal Er3-compartment sink -Er Electrical hook-ups <br />er Solid waste disposal a Food preparation ET- Toilet and handwashing <br />'Hot & Cold water for cleaning Er Store refrigerated food Er Potable water <br />Er Store dry food/sup5p ies 0/ Overnight parking ErVehicle wash <br /> , 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 sha . EHD immediately. <br />Signature Date 6-/ - oz --/ <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co.] <br />_S- n _610M:11T> The commissary is located in 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 fri C..LJGtrf Date qmfr,z-i- <br />L.1 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd