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SANJOAQ U I N Environmental Health Department <br /> --COUNTY <br /> G,r atnrts grnws Kerr. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility f, Caterer <br /> Complete socffons 1 and 2. If your commissary is located oufsldo of San Joaquin County also complete SeCtlon 3, <br /> 11. To be completed by APPLICANT - - <br /> Business Name Raunak Bazar Food Lic.Plate# 44B4482 <br /> Owner/Operator Name Man reel Sin h Sra <br /> Business Mailing Address 2151 Moffat Blvd <br /> City I0inteca State CA Zip 9533fi Bus. Ph. 448-996-7019 AI I. <br /> Ph. <br /> 1, t0ancree S. Sr., ,hereby state that the above information is current,true and correct to the best of my <br /> knowledge and agree to utilize my approved commissary in accordance with California Health &Safety Code, <br /> and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary <br /> is discontinued, the permit holder must n ' the EHD. Failure to notify this office may result in permit revocation <br /> and penalties, <br /> 5tana ore ..�� Date 10 .21- 20 3- S <br /> , 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name C FA# <br /> Address Zo , Bus.Phon C 2- <br /> City 1Ll:�� Zip S Z LA Owner/Operator <br /> Check all appropriate services provided: <br /> 10 Wastewater disposal X 3-compartment sink 23 Electrical hook-ups <br /> Solid waste disposal D Food preparation 12 Toilet and handwashing <br /> Hot&Cold water for cleaning [3 Store refrigerated food EZ Potable water <br /> 13 Stare dry foodlsupplies A Overnight parking Q Vehicle wash <br /> 1. _ tom' ' _ , hereby state that the information i have provided is current,true and <br /> collect to the best ofmyAnowleage,and meets the California Health&Safely 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 shallAotity the EHD immediately. <br /> Signature Date I 21 <br /> be-` Pleted by the ENV HEALTH 'urisdif tion outside of San Joa uin Ca.� <br /> The commissary is located In County. The above food facility meets the <br /> commissary requirements inCalifornia Health & Safety Code. The above chocked services are available at the <br /> above commissary, Please notify EHD if the status of their operating permit changes. <br /> REHS Signature D11e <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 kv%%-%v.sjgov.org,'ehd <br /> �R0S� �'I <<� <br />