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<br />ty- <br />SAN JOAQUIN i'at <br />Oliveros Distribcrw- <br />Commissary <br />145 S. Kilroy Rd <br />Turlock, CA rhvironmental Health Department 209-634-200 <br />COUNTY <br />Greatness grows herp <br /> <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 />To be completed by APPLICANT <br />Business Name OXLA 0._oc\-e3 <br />Owner/Operator Name JeArej- ci\os,5NAAA <br /> <br />Lic. Plate # LOIS1 <br /> <br />Alt. Ph. <br />, 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. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary NamedNea7S birly\--LAI Coft/vv\--N“cl- FA# <br />Bus. Phone 3-0 01) l- -o 0 <br />City ¶Lir k, 0 zip 015-3Y0 Owner/Operator c\CXSe S 01; vez-b <br />Check all appropriate services provided: <br />ErWastewater disposal <br /> <br />e'3-compartment sink <br /> <br />atlectrical hook-ups <br />Solid waste disposal <br /> Er Food preparation <br /> <br />'Toilet and handwashing <br />CrHot & Cold water for cleaning EStore refrigerated food <br /> <br />PrPotable water <br />-Erit-ore dry food/supplies Q-01vernight parking EKehicle wash <br />I, (...\f)1.--Se s Ckr e-ct75 , hereby state that the information I have provided is current, true and <br />correcrfo 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 tht EHD immedia ly <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in a_u-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 EHD if the status of their operating permit changes. <br />(-1 -tf- cl I (i 3 Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Business Mailing Address Zap% 0.0011:643+2, ?‘ <br />City Ka(-\\-et_at_ StatetA- Zip% 3?) 7 Bus. Ph. <br />I, jcnverl-cer <br />74a4.42aLo_f_ Date / //1/2,5 <br />Address 1(45 5 • k't ro y <br />Signature's _ (cve_Yd).-J91Date oijiy/a5- <br />REHS Signatu <br />125 0024,94