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SAN-JOAQUIN Environmental Health Department <br />--COUNTY- <br />-- <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 9 and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT 1r V5 <br />Business Name L AIA'�> i e_ 2G Lic. Plate1 c� a) <br />Owner/OperatorNameAzya a,ggln z&iwea1e FNt <br />Business Mailing Address oIA6 q5- E Alwy /2d <br />City,A"y State-cgLZip 75-3-20 Bus. Ph6 Qc()1/VS 37 95AIt. Phl-2,0V) yn-57� 9I <br />I, t 0 hereby state that the above information is current, true and correct to <br />th best of my knowledge a d afire o 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 />2. To be completed b// COMMISSARY OWNER/OPERATOR <br />Commissary Name Za Gnmfl wria FA# NJ4 <br />Address 1211 5. -)L"4 .1 ree.F- Bus. Phone Cto9) 33Fs -3663 <br />City Awles4-e Zip 4535.5 Owner/Operators/d 3?6mge <br />Check all appropriate services provided <br />W Wastewater disposal <br />y} Solid waste disposal <br />1a Hot & Cold water for cleaning <br />0 Store dry food/supplies <br />1Z 3 -compartment sink <br />1$ Food preparation <br />Gil Store refrigerated food <br />M Overnight parking <br />Z Electrical hook-ups <br />0 Toilet and handwashing <br />lB Potable water <br />R Vehicle wash <br />I, Afark , 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 Date /2-112 —7-( <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in s4 ✓r,i c lam, AjX' 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 Sianature r0 Y!/ ! // Date / l /'; / /c- <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br />