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Co ,.„,4 ssary <br />145 . Kilroy Rd. <br />Turlock, CA ono <br />209-634-2000 <br />4,14. <br />The commissary is located in <br />commissary requirements in Cali <br />above commissary. Please notify <br />REHS Signature <br />/4',14,u114. COunty. The above food facility meets the <br />ealth & Safety Code. The above checked services are available at the <br />f the status of their operating permit changes. <br />a <br />Date <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />--COUNTY----- <br />GrEainEss 9rows. her. <br />Olive <br />10.10 <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <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 AKA (ji 13 <br />Owner/Operator Name -712__SU <br />Business Mailing Address \5C\ jz1S-e.ii•A't Q-4? <br />City VA (11\ StateC-(\ Zip cp5-33.i. Bus. ph.50„ q63----N34,1t. Ph. <br />Q V..42 IA7( ç , hereby state that the above information is current, true and correct to <br />the best of my knowledge-QM 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 />Lic. Plate <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />i <br />Commissary Name <br />Address ILI 5, 1<:. ‘1 I fro c., gcl_ Bus. Phone ( " 24 7q) t 3 6/ - a b - 0 0 <br />..// ," <br />City .11 ,/ i 0 ct- Zip 7, . ,--, kUOwner/Operator D----irk-v-) cl -5-e / -/-7-q,--) <br />Check all appropriate services provided: <br />orWastewater disposal 2'3-compartment sink Er Electrical hook-ups <br />a Solid waste disposal Er' Food preparation ErToilet and handwashing <br />12 Hot & Cold water for cleaning 21Mtore refrigerated food Cr Potable water <br />CN-'0 el Store dry food/supplies Er Overnight parking Vehicle wash — <br />I, -.1(fr'rl-.1 --ete / ef yl. , hereby state that the informati n I have provicis 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 no2y_te EHD immediately. <br />Signature <br />...— _ . <br /> Date r3 '-- 7 - 2-r) --2. 5 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />1868 E. Hazelton Avenue I Stoc ton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />0 (49g