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SAN ' JQAQUIN Environmental Health Department <br /> L, 5 i= = COUNTY----- <br /> �, _ Gre+stness grows hero. <br /> Co sail <br /> i s <br /> COMMISSARY AGREEMEN Turlock,:,CA 95 3 <br /> SQ <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 V- AA C. -k E :J ++�y L.ic, Plate#_ <br /> Owner/Operator Name g SU S �k tiZi <br /> Business Mailing Address <br /> city ViAI C..(-'\ {�StateC;{' Zip � 'J9" L Bus. Ph.G5(3- q6l- 1g3j41t. Ph. <br /> I, C' !1p L. r , 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 V <br /> 2. To be completed by- COMMISSARY OWNER/OPERATOR <br /> Commissary Name U S , 1 r A# <br /> Address 1C (C) Bus. Phone <br /> City Zip _53 �OwnerlOperator <br /> Check all appropriate services provided: <br /> Wastewater disposal Q'3-compartment sink CrElectrical hook-ups <br /> [2 Solid waste disposal Hr Food preparation ErToilet and handwashing <br /> 17 Hot & Cold water for cleaning Store refrigerated food ff Potable water <br /> Ef Store dry food/supplies Pf Overnight parking Qf Vehicle wwash <br /> ►')'� Gt ' hereby state that the informati n 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 /> Signature -- Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary41Stoc <br /> t <br /> � County. The above food facility meets the <br /> commissary req ith & Safety Code. The above checked services are available at the <br /> above commissa status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazeltoon, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> VRD5u(P(;2 <br />