Laserfiche WebLink
SAN JOAQUIN <br /> <br />Environmental Health Department <br />C NT Y•-- <br />Grv:;:rh7ic <br />k <br />COMMISSARY AGREEMENT 2--t• <br />Mobile Food Facility * Caterer <br />Oliv <br />Col•11 " sary , <br />14 'Kilroy Rd <br />Turlock, CA 9538.1 <br />20934-2000 <br />Scanned with <br />CamScanner- <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />be- ctiniOletaby APPLICANT <br />Business Name gisyAt <br />Owner/Operator Name I.J--ifea_Q Ni\c!ko,L-v\ <br />Business Mailing Address I j-6 <br /> <br />Lic. Plate # 1Y-79 <br /> <br />vz_sc,i Stater-A- Zip c\ sr-3 Bus. Ph. 2-n 61 6 9 4.- Alt. Ph. <br />1, Q-0 INTeacv , 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 />Signatur <br /> <br />Date (-)/ / <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 01;detro51)54-1;b4; 00 CD mni i556!:_y4A# <br />Address 1(15 [boy eci-- Bus. Phone ("Z"Dq) 6 3 c-/-2.0 <br />City Ti4 TO Zip q3 --0 Owner/Operator Zv vv)q <br />a3-compartment sink <br /> <br />Er-Electrical hook-ups <br />2'Food preparation <br />E'Toilet and handwashing <br />,ErStore refrigerated food <br /> <br />'Potable water <br />ErOvemight parking re"Vehicle 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 notify thJdD,imrnedlately. <br />Signature <br />-rtditiffireted by the ENV HEALTH jurisdiction outtide of San JóaquIflCO ._ <br />The commissary is located in g+A \5VAk.)5 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 />0 <br />RENS Signature <br />1868 E. Hazelton Avenue Stockton. California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.orgietid <br />City <br />Check all appropriate services provided: <br />erWastewater disposal <br />112(Solid waste disposal <br />ErHot & Cold water for cleaning <br />Er-Store dry food/sup lies <br />I, -1-irrierEe q <br />Date J —//'22,'S <br />Date V! '/2O25 <br />25002ift