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Environmental Health Department <br />\1 <br />k_. <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 <br />Date <br />Vehicle wash <br />/-IDate <br />Date <br />pisuib«jPi> <br />iSsary <br />^Kilroy Rd <br />-Q^EIectrical hook-ups <br />Toilet and handwashing <br />0^Potable water <br />Olive] <br />Cona <br />14: <br />Turlock, CA 95380 <br />209-634-2000 <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />I <br />| Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />•s-aa f ■ <br />: Scanned with <br />—. CamScanner <br />Overnight parking <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 the EHD immediately. <br />Signature <br />SAN JOAQUIN <br />COUNTY <br />Grentnc^ zro.-.-- hr- <br />Lie. Plate# hT V V3 7 / <br />2. To be completed by COMMISSARY OWNER/OPERATOR_____________ <br />Com mis sa ry Name Q lid C/ (75 FA# <br />Address. W-> 6, L ~,l1/ pu __Bus. Phone <br />City Zip ^7^0Owner/Operator <br />Check all appropriate services provided: <br />EY 3-compartment sink <br />Ef Food preparation <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 />REHS Signature, <7^ —Date, 1/17/2025 <br />1868 E. Hazelton Avenue <br />Ef Wastewater disposal <br />eTSolid waste disposal <br />Hot & Cold water for cleaning eTStore refrigerated food <br />e/ Store dry food/supplies <br />1. "TZf nner Va?, I Ayq <br />Afy JYl ________ <br />Owner/Operator Name A, i/d: <br />Business Mailing Address <br /> Clf^^^TT^^^tate Bus. Ph.SZ Alt. Ph.^S-S^^ 0 o o cy <br />I. 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 hqider must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature 1