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SANvJOAQUIN Environmental Health Department <br />—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 -Thc Grazing wG�lrl Lic. Plate# 11�A <br />Owner/OperatorrNam Navarro <br />Business Mailing Address 1485 Sereno Drik. <br />City -MI cQ state CA zip -15 3 31 Bus. Ph.415 606 4D15 It. Ph. n10 <br />I, Teresa qVQ rYp , 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 ypRi/enalties. 1 <br />Signature �fezm'-�MGVt'►$ Date 212312-D23 <br />2. To be completed ti COMMISSARY OWNER/OPERATOR <br />Commissary Name I(.\�QV VOna irijat c_e_ L( -c- FA# I 2� <br />Address Bus. Phoneto 2- \ <br />Check all appropriate services provided: <br />p Wastewater disposal 1 -3 -compartment sink 0 Electrical hook-ups <br />'$ Solid waste disposal '$rood preparation Toilet and handwashing <br />Hot & Cold water for cleaning ![Store refrigerated food E3 Potable water <br />- Store dry food/supplies O Overnight parking O Vehicle wash <br />I, �Cn i YYLP Lqf c. _ , 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 51 at shall notify the WD immediately. <br />Sig <br />3. To <br />2-'zy - 23 <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in Califomia Health 8 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 Sionature <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />