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MAR, 0 4 2026 <br />Lie. Plate# <br />Date REHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 lwww.sjgov.org/ehd <br />COZbODOm <br />PiZ 2So^ SSH <br />Environmental Health Department <br />RECEIVED <br />X SANJOAQUIN <br />—-COUNTY----- <br />Greatness gr&ws here. <br />Date I 7 0 2 £ <br /> Electrical hook-ups <br />^3 Toilet and handwashing <br />Potable water <br />Vehicle wash <br />M. To be completed by APPLICANT ’ ‘ _ | <br />BusinessNameTOR-TlltR-l ft 1^0 NA^ A Lic. Plate# Hwbivyz <br />Owner/Operator Name IfaNACiQ VILLA EHSEA _ <br />Business Mailing Address. HU N- ^Lii'E kx/t <br />City Nstate LAzio 5 2/SBus. Ph.(7.0^) 9 j/~ 7^5~ Alt. Ph. <br />i,l£)h/AL|0 Cl .IS FA , 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 <br />■ <br />^S-Food preparation <br /> Store refrigerated food <br /> Overnight parking <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 compjyjyiih the condition-; of this agreement, or if this agreement is modified or cancelled, the <br />commissary owrW^gll noti^fT^aft&JmjJbdiately. <br />S i g n a tu re_____‘316 ^3/07 / 207L, <br />3. Tobe co/ripfeted by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary<is4ocated 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 />j <1 KJ A< (Q \ J11 z'A, 11 <br />| 2. To be completed by COMMISSARY OWNE^R/OPERATOR <br />Commissary Name VNl0(\j LATE HNLi TR-V^K AENTLA <br />Address HO S- \JNI6N ST BUS. PhoneLlOfl i <br />City ST?)CK-TD |\/ Zip 7.0 V Owner/Operator <br />Check all appropriate services provided: <br />l^Wastewater disposal ^3-compartment sink <br />Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i. VESlILA Tz9TA <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3.