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y SAN J OA Q U I N Environmental Health Department <br /> ' ----COUNTY <br /> Gregtness grows here. <br /> 011ve Distrfucticst. <br /> Co . ssary <br /> Kilroy Rd. <br /> �,k"',c Ki <br /> COMMISSARY A G R E E M E N T, 145`,.,.�„��. Turlock,CA 95:80 <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 /> Business Name I-A (-AA QAA ;v Lic. Plate# <br /> Owner/Operator Name 12 v � +241� �Zi � v <br /> Business Mailing Address_ ��1 (-P `f ye_ <br /> City :)1•+ ',.A StateCP� Zip v.)-3" L Bus. Ph.G5(D- -2G3--V3�4glt. Ph. <br /> �1 - <br /> I, C' .�l �. hereby state that the above information is current, true and correct to <br /> the best 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 /> Signature Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name � �V QiVV S �� 41, t ` vn I✓(�JLs9/19� i�uFA# <br /> Address Ig 5 P� l 1 1'0 (4 PCB Bus. Phone <br /> City Zip �L5_3�Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 13'3-compartment sink O'Electrical hook-ups <br /> O' Solid waste disposal Er Food preparation frToilet and handwashing <br /> la Hot & Cold water for cleaning Store refrigerated food d Potable water <br /> El Store dry food/supplies Ef Overnight parking Vehicle wash <br /> 1, :PM 4i &/ -�ii kl , 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 notify the EHD immediately. '2 <br /> Signature M^ [pateJ <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />