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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <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 />To be completed by APPLICANT <br />Business Namefhanni 11-1. nrpArn <br />Owner/Operator Namer hanan Ram <br /> <br />Lic. Plate # qz,liggcas- <br /> <br />Business Mailing Address 1.574 VetPlail <br />City u.ntecA <br /> <br />State (1,4 Zip cig37 Bus. Ph. AR9245q171 Alt. Ph. <br /> <br />I, rhanan Ram 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 ACr.tAZ./(-4 , - <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name m /I( .c-i-ne ice FA# <br />Address Li/ .a(ii/6-7 <br />Bus. Phone a -) 7) _L/I7, 7 <br />City 7.77 /7:.3----ri: <br /> <br />Zip C, c- ;7 Owner/Operatori-:11 I-I fie <br /> <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />'‹ Store dry food/supplies <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />'K Electrical hook-ups <br />'‹ Toilet and handwashing <br />Potable water <br />Vehicle wash <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 p C• Date 6103/ .1-1 , <br />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 Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I wwvv.sjgov.orgiehd <br />Date (1S/02/2024 <br />P(2- Ong 1-