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SANJOAQUIN Environmental Health Department <br /> L-wi ; —COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <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 nu-i ri (ll' Iyl Lic. Plate# �01353 <br /> Owner/Operator Name Niftlat &42- <br /> Business Mailing Address ZHhl N, TT99. <br /> City0 State�Zip C152zU Bus. Ph.Vq''U"5—lt Alt. Ph.'2O1-ja -2 111 <br /> I,- Z(lfGU 9(k)KiMZ , 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 holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. �� <br /> Signature / Zi Date���2�2022 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name awmastALvi ( FA# <br /> Address / ISG � S Bus. Phone <br /> City L �,/ I Zip] -Owner/Operator o ! z <br /> Check all appropriate services provided: <br /> p' Wastewater disposal O 3-compartment sink 1�r Electrical hook-ups <br /> JW Solid waste disposal O Food preparation K Toilet and handwashing <br /> gr Hot& Cold water for cleaning O Store refrigerated food Potable water <br /> 0 Store dry food/supplies �r Overnight parking [Vehicle wash <br /> I, ���%90CA Z , hereby state that the information I have provided is current,true and <br /> correct to the best of my knoVA1 ge,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 nqM no ' the EHD iimmpediately. <br /> Signature `v/ Date <br /> 3. To be completed by the EtDAEALTH 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 Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />