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SAN3JOAQUIN <br />- COUNTY— <br />Gregtness grows here. <br />Environmental Health Department <br />su'a <br />COMMISSARY AGREEMENTz-',' <br />Mobile Food Facility. Caterer <br />Olive Distribegw. <br />Co 1,;, ssary <br />145 . Kilroy Rd. <br />Turlock, CA 953SO <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 /> <br />" Lic. Plate # <br />Owner/Operator Name TAa5U tkd (\- v <br />Business Mailing Address \5C\ <br />City VtfNIAC (IA Stated' Zip (4=5-334. Bus. Ph.G50- 6 3---IN.3L18‘lt. Ph. <br />T,Tes1/4.) tAk...Sk QA 2hryc , hereby state that the above information is current, true and correct to <br />the best of my knowledge 'id 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 />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name %iy..P,4/.0 5 <br />Address IL/ ,k Bus. Phone (2(>1) b39- <br />City ."1-4 / 0 ct. Zip C,'53w2Owner/Operator / "/"Tc),-) <br />Check all appropriate services provided: <br />E'3-compartment sink <br /> <br />0-Electrical hook-ups <br />E3' Food preparation -erToilet and handwashing <br />OrStore refrigerated food <br /> <br />ti Potable water <br />Dr Overnight parking -11Vehicle 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 shall notif the EHD immediately. <br />-- <br />Signature <br />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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />Business Name <br />Date (-) 1 2 <br />Er-Wastewater disposal <br />ct Solid waste disposal <br />GI Hot & Cold water for cleaning <br />Ei Store dry food/supplies <br />I, --.(t'r) —64' I 41,'Ci <br />pate "3