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ej I 7 (2-0 Date <br />RENS Signature el <br />n2-0 5(7 <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Olive/ Disulb,.:11,e <br />Con s". sary <br />14 :v. Kilroy Rd <br />Turlock, CA 953P4 <br />209-634-2000 <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 />Owner/Operator Name „r,gfl f <br />Business Mailing Address j3 5,C <br />C14/ olirrceSoAstate AZip 63-S-A3 Bus. Ph. a ui 3 3 Alt. Ph. q 0 9 <br /> <br />\Y \QZ , 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 hojder must notify the EHD. Failure to notify this office may result in permit <br />revocation arld_ofinalties. <br />Signature - <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 0 e r b) Oil a in/WI 554 Vi FA# <br />Address /(/ 1'7 S. k_dv o ci Bus. Phone (-aipci) (73 9 - <br />City 1.—t/1 ih7C—L Zip <br />Check all appropriate services provided: <br />Er Wastewater disposal <br /> a 3-compartment sink <br />I'Solid waste disposal <br /> <br />Er Food preparation <br />ci <br />Ef Store dry food/supplie* CrOvemight parking <br />Hot & Cold water for cleaning 'Store refrigerated food <br />l,f1C Vk , 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 />the EHDjnmediately. <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />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 />Business Name c.t. a& u lic. Plate # 11-77 73 7 / <br />e- 2 <br />Owner/Operator E-e c? <br />„GrElectrical hook-ups <br />ErToilet and handwashing <br />ErPotable water <br />ErVehicle wash <br />commissary owner <br />Signature Date I I - -7o 2-5 <br />The commissary is located in <br />Date V 2L25 <br />1868 E. Hazelton Avenue( Stockton, California 95205 T 209 468-3420 F 209 464-0138 wvmsjgov.orgiehd <br />Scanned with <br />CamScanner