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SAN JOAQUIN Environmental Health Depa <br /> rtment <br /> — <br /> COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 7 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_26ks—p I��TG Lic.Plate# '1 M gS(o 4A0 <br /> Owner/Operator NameNapoipc�— Co <br /> Business Mailing Address (Q& E59 Ol F i't: n K l 1 n Ud <br /> Citv.( cnCM Y MTtl StateLA_ZipGg _4 Bus. Ph.6jj4 W-)- Gii`.-q Alt. Ph.cjjb)1()(fl -8(DLAL <br /> i, V t r i dinnn NaPalQ s hereby state that the above information is current,true and correct to <br /> the best of my knowledg6 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 an) <br /> penalties. / <br /> Signature,yi NjA-Gt4-, pV�pd)� G Date OS 1— <br /> /1 -3 /2 1 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName 1()j C, k)r)0jj2tOt FA# 00S_2LQ-n <br /> Address ;-4()l PreirNKIl in Nck Bus. Phone oll :m7 - 41 15G1 <br /> City<a�dr)P.nr0 ZipG1S!a2,A Owner/Operator -\)JridiQnck Nnpo i es <br /> Check all appropriate services provided: <br /> Wastewater disposal C(3-compartment sink Electrical hook-ups <br /> Solid waste disposal d� Food preparation Ef Toilet and handwashing <br /> 2f Hot & Cold water for cleaning GT/Store refrigerated food ff Potable water <br /> Store dry food/supplies r2" Overnight pbrking ® Vehicle wash <br /> I, Vi j dlanca Nopoles , 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 c ditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissar �o�er shall noti t�'HIDediate) <br /> Signature yV✓^i /n...a ty Date 05ll7// <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in �(/(d�� 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 stat of <br /> their operating permit changes. <br /> REHS Signature�C=yC� / - Date U G <br /> if <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 />