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•M <br />Environ <br />a <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 4 <br />Date IL-IZ-ILS <br />r <br />Date <br />LeitU Date REHS Signature <br />1868 E. Hazelton Avenue [ Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />&'3-compartmentsink <br />ETFood preparation <br />O' Store refrigerated food <br />O’ Overnight parking <br />□"'Electrical hook-ups <br />□“ Toilet and handwashing <br />d Potable water <br />Vehicle wash <br />FA# <br />Health Dibartment <br />"S- <br />Lie. Plate# quj, pfru <br />145 S. KILROY RO <br />TURLOCK CA, 95380 <br /> COMMISSARY AGRBOEN^ <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />-------COUNTY------- <br />Greatness grows here <br />_________Bus. Phone <br />Qwner/Operator 2 J <br />Fa 5 i S____________ <br />Owner/Operator Name Ct’ (u jU/l U rJccLv? <br />Business Mailing Address ?. c ■ <br />City State CA Zip Bus. Ph. 20A-,^3"OrfXte Alt. Ph. <br />X C Lj cJcuU-D,, hereby state that the above information is current, true and correct to1.. <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 Gt <br />TTo be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name ±LtJUl <br />Ad dress_2 I _______ <br />City | Uv Zip <br />Check all appropriate services provided: <br />Cf Wastewater disposal <br />ET Solid waste disposal <br />ET Hot & Cold water for cleaning <br />El Store dry food/supplies <br />1., 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 />commissaryziwner shall notify the EHD immediately. « <br />Signature^yU* Date I f Z <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co, <br />The commissary is located in 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 />P. rtj > q