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»� Oliveros Distr, <br /> Commissary <br /> d <br /> IN Turlock,CA 10AQU vironmental Health Department <br /> -f COUNTY <br /> Greatness grows her(=. <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 J <br /> Business Name b-u!Srxx �O n�S -7 Lic.Plate# `Z Ore 3 7 <br /> Owner/Operator Name JeA Y\ n1 Cola\` <br /> Business Mailing Address cZUa%_(Ioot�&Wg— Q\ <br /> city �Aaa�ceLcL State &_Zips 3' 7 Bus. Ph. Alt. Ph. <br /> 1"Jetonn y� t' ar'n bRA` , hereby state that the above information is current,true and correct to <br /> the best of my knowledge and 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.Signature16kc)LIOL� Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name %VAS sAtJ-�r)/) FA# <br /> Address (L(C7;' 5 k't I Iro Y IZ Bus. Phone L/-d-O O 0 <br /> City T yr O C'V_ Zip 0I5_380 Owner/Operator do y Lx/5 01,V(,a'b� <br /> Check all appropriate services provided: <br /> B'Wastewater disposal ET"3-compartment sink electrical hook-ups <br /> d'Solid waste disposal CFood preparation eToilet and handwashing <br /> Hot& Cold water for cleaning E f5tore refrigerated food (Potable water <br /> Store dry food/supplies CI-6vernight parking $Vehicle wash <br /> 1, 30 � S O�'%v e,-V ,hereby state that the information I have provided is current,true and <br /> correct o the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails t comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary r shall notify thf EHD immedia ly I <br /> Signature)\ !� C� ey'a 0 I / l y/a"� <br /> 3 To be completed by the <br /> y �ENV HEALTH jurisdiction outside of San Joaquin C <br /> 3o. <br /> The commissary is located in G-n-t S (0_ 'S 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 EHDY if the status of their operating permit changes. <br /> REHS Signatu' < ?� �d1� 2�rf S-t i l Date Zo z S <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> 11225 00ZWi4 <br />