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SAN JOAQUIN <br />--COUNTY - --- <br />Gn,..5:7 tii-o?/-7. here. <br />o <br />EtwronrneFrlth Hafth Dep rt ent <br />RECEIVED <br />COMMISSARY AGREEMENT MAR 2 6 2024 <br />ENVIRONMENT <br />Complete sections 1 and 2. If your commissaty is located outside of San Joaquin CountV <br />AL HEAL1 r <br />WIT/SE,RVICES complete section 3. <br />1. To be completed by APPLICANT <br />Business Name <br />Owner/Operator Name 1/Tna.A.Lo‘k/ <br />Business Mailing Address / 7/17 Ai Vjezia <br />Citap_a Stateal Zip yceioq Bus. Ph.,;214 -rd 72 Alt. Ph. <br />I , Naga /1eelt_A-14.0 z._7-hereby state that the above information is current, true and correct to gLe5-42 <br />the best of my knowledge and agre ' 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, e permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penaltie 6--- <br />Signature Maki <br />Mobile Food Facility* Caterer <br />Lic. Plate # qUP5-1-) <br />'CICX Date ;4-677 ‘. <br />14 Electrical hook-ups <br />Toilet and handwashing <br />d Potable water <br />Vehicle wash <br />2. To be completed by COMMISSARY OWNER/OPERATOR /lamizzLi <br />Commissary Name lik (-- . FA# <br />Address <br /> <br />a}7 dilfa)Or-/-1 Bus. P h op e g- 9 I/0 if - 11 C -7, a2--9.& e-7, <br />City -C240 Zip 75-010 c Owner/OperatorA , A . a}1412,t, <br />Check all appropriate services provided: <br />Wastewater disposal <br /> Ei 3-compartment sink <br />[tt Solid waste disposal <br /> Food preparation <br />LI' Hot & Cold water for cleaning <br /> 12 Store refrigerated food <br />0 Store dry food/s lies y, Overnight parking <br />I , 0 AlAtik.: EA /1/4/1dt , 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 • comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissa o rer shall I. .- -,• - . a ely. <br />rvi_f___ Date „71_ - <br />Signatur 40111111m.....— <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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd