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S A N J O A Q U I N Environmental Health Department <br /> --COUNTY <br /> Grar,fneSS �roa+s hers. <br /> Oliver isur�, <br /> t com�y <br /> COMMISSARY AGREEMENT �`�"` 145 troy Rd <br /> Turlock,CA 95Y' <br /> Mobile Food Facility + Caterer 209-634-.2000 <br /> Complete sections 1 and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be com leted by APPLICANT <br /> Business Named Liza Lic. Plate <br /> Owner/Operator Name? �' - <br /> Business Mailing Address <br /> City _T_1oj State<aZip 536313us. Ph. 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 _ Date <br /> 2. To be Completed by COMMISSARY OWNER/OPERATOR <br /> u.� <br /> Commissary Name fsr r -k-� 6 cf FA# <br /> Address �j S �► ✓ rJ cr cL Bus. Phone 7 e� t� — Zoe o <br /> City ��t ✓ rr yC Zip C! 5,39'D Owner/Operator -'7 <br /> Check all appropriate services provided: <br /> [ 'Wastewater disposal 0"3-compartment sink Ef Electrical hook-ups <br /> Ef Solid waste disposal I-Food preparation .-Toilet and handwashing <br /> Ef Hot& Cold water for cleaning Ef Store refrigerated food Potable water <br /> O'Store dry foo/su plies E!(Overnight parking Vehicle wash <br /> G �e I ci hereby state that the information l 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 modifred or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> Signature Date <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 Cali ornia Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify D if,the atus of their operating permit changes. <br /> REHS Signature Date 1-1 1 20Z5 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 7 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> 9RISDDXAVC) <br />