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S A N _J 0 AQ U I N 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 R,�gnantnj;tn- I a chijnalPta Lic. Plate# <br /> Owner/Operator Name\1 rirjiana na m nnlac y <br /> Business Mailing Address 5701 Franklin blvd suite D <br /> City Sacramentn State CA Zip 95824 Bus. Ph. 9167068662 Alt. Ph. <br /> I, Viridiana Napoli-,,; coy , 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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Viridiana napoles coy FA# <br /> Address 5701 Franklin hlvd snita n Bus. Phone <br /> City Sacrampntn Zip 95824 Owner/Operator /iririiana Glc@PnipS <br /> Check all appropriate services provided: <br /> Wastewater disposal je3-compartment sink electrical hook-ups <br /> Af Solid waste disposal .R-0food preparation /47 Toilet and handwashing <br /> eJiKiot & Cold water for cleaning Store refrigerated food Potable water <br /> S `tore dry food/supplies DL Overnight parking /Vehicle wash <br /> I, Viridiana napoles coy , 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 f this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD im , ly. <br /> Signature Date o6/19/2024 <br /> 3. To be completed by the ENV H ALTH 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> J?r2 2 q V 2 <br />