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SAN JOAQUIN <br /> <br />Environmental Health Department <br />1 • -COUNTY <br />Greatness grows here <br />COMMISSARY AGREEMEN <br />Mobile Food Facility Caterer <br />Olive fDisuit,m,. <br />Co u sary <br />145 .y Rct <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 aco& 1 &oeao &Oct Lic. Plate # 4-r2_39L4a <br />Owner/Operator Name Ern 'ill Vi@il Abel <br />Business Mailing Address 353 1--eilllY10 4- <br />City ilive.riDoL State CA Zip C1536-7 Bus. Ph.000-7(o5 -3-3 610 Alt. Ph. <br />I, Er(lAM , hereby state that the above information is current, true and correct to <br />the best of-lny 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 Date 10 —(9" Z-OZV <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 0 /1eie-1055 D-b4rie„to w4--i-tfi FA-4 /227/9- <br />Address j <br />Ij <br />- 5 • broc,, <br />„ <br />Bus. Phone (2-q) L.3 Zv <br />CitylV(., (1, (2 CAC.- Zip q37 Owner/Operator .41.0/ •Ze <br />Check all appropriate services provided: <br />a Wastewater disposal <br />er Solid waste disposal <br />le 'Hot & Cold water for cleaning <br />Er Store dry food/sur ies <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 <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in -6W1V) Oas 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 />ef) <br />En-compartment sink -a-Electrical hook-ups <br />kr Food preparation -er Toilet and handwashing <br />ErStore refrigerated food <br /> er Potable water <br />'Overnight parking E'Vehicle wash <br />Date <br />REHS Signature iiteL <br /> <br />Date <br /> <br />1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 I F 209 464-0138 www.sjgov.org/ehd <br />pe.osLite \