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. .•,,,,SANJOAOUIN ., . ...: <br />-COUNTY <br />Greatness grows here. _. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Olive Distni.n.axe <br />, mac Co ssary <br />145 . Kilroy Rd, <br />Turlock, CA 95380 <br />Mobile Food Facility + Caterer 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 />Lic. Plate # q'S <br />11 5 in <br />Business Mailing Address CA -2>e CY Y1.4 Y) Lk) <br />City Re.1a, State 0 letZip 96.317(Bus. Ph.1(21" 6 56 W 31/41t. Ph. <br />c‘.`r *v\ ')c , hereby state that the above information is current, true and correct to <br />the best of my knowledgeand 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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 0 R'(O LMO arnm.s5g4r# <br />Address (-1 6 5 . tiro, g.1_ Bus. Phone (7Z09) 9 - 20 t) <br />City TEA 40 CL- Zip 9 5yo Owner/Operator ---1,-.Y*-fzt. <br />Check all appropriate services provided: <br />r'Wastewater disposal Cr3-compartment sink ErElectrical hook-ups <br />g'Solid waste disposal iErood preparation CI-Toilet and handwashing <br />EKot & Cold water for cleaning CrStore refrigerated food tr-Potable water <br />erStore dry food/sup9Ii9s Er Overnight parking ehicle wash <br />I, %erbet Sei 4)(11,-) , 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 noti ediately. <br />Signature <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />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 <br /> <br />Date tbl <br /> <br />Business Name t o..sexs) C1/4.\0-4 1.e "\6 <br />Owner/Operator Name -..ctirre'S <br />Date <br />Date C° 7 7-0 Zq <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />.121z2L- OJ T? '35