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S N J o A Q N Environmental Health Department <br /> .-COU NTY--- <br /> �31"C:7�fic55 �f'C'rVS, 11c5f".-. <br /> oliv? iDistAb,; .0 i <br /> Q dui Coi ssary i <br /> t•' {' 145 r tlroy Rd. <br /> COMMISSARY AGREEMENT`r ':A Turlock, 1 <br /> Mobile Food Facility ,� Caterer 209-634-2000 � <br /> Complete sections 9 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 1-A i AA C.k C- Q Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address V 30A "'X'k �c Q-f <br /> City ai-+ `, StateC: Zip � �3'� � Bus. Ph.�5(:)-- ,It. Ph. <br /> Tth <br /> �, ( Q , hereby state that the above information is current,true and correct to <br /> est of my knowledge,- d 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 /> Da Signature te <br /> Zk <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ��` V S �,� ti ��;,,�t ` vLT <br /> Address I�-/ 17 Fro to d Bus. Phone ��J��/1- Zz'C, <br /> City '�,r� d 0 �� Zip �y3ST2 owner/Operator � � <br /> Check all appropriate services provided: <br /> ff'Wastewater disposal C 'r3-compartment sink WElectrical hook-ups <br /> Cr Solid waste disposal 0'Food preparation ErToilet and handwashing <br /> (7 Hot & Cold water for cleaning .Store refrigerated food Potable water <br /> E Store dry food/supplies ff Overnight parking �N_Q� f \� �) Vehiclle <br /> .� ided e wash <br /> I _:PM G� �E'1 7��;n hereby state that the information I have prov 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_ fVthe EHD immediately. <br /> Signature Date �� Z <br /> 3. To be completed b the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in Nr County. The above food facility meets the <br /> commissary requirements in Cali is eialth & Safety Code. The above checked services are available at the <br /> above commissary. Please notify D the status of their operating permit changes. <br /> REHS Signature V Date <br /> 1868 E. Hazelton Avenue I Stoc ton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> x0sg1 (69 <br />