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Date REHS Signature <br />SAN JOAQUIN <br />—COUNTY— <br />Greotness grows here. <br />Environmental Health Department <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 Name Raspantnjitns I a chupalAta <br />Owner/Operator Name Viridiana nproies roy <br />Business Mailing Address 5701 Franklin blvd suite D <br />City Sacramento State CA Zip 95824 Bus. Ph. 9167068662 Alt. Ph. <br />I, Viridiana Napoles 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 rnust notify the END. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Viridiana napoles coy Commissary Name FA# <br />Address 5701 Franklin blvd suite D Bus. Phone <br /> <br />City Sacramentn <br /> <br />Zip 95824 Owner/Operator viridiana napo tes. <br /> <br />Lic. Plate # <br />Date <br /> <br />Check all appropriate services provided: <br />Wastewater disposal 3-compartment sink <br />off Solid waste disposal ood preparation <br />saie-lot & Cold water for cleaning gStore refrigerated food <br />SStore dry food/supplies Overnight parking <br />Zlectrical hook-ups <br />leToilet and handwashing <br />/Potable water <br />Vehicle wash <br />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 of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD imrir <br /> <br />HEALTH jurisdiction outside of San Joaquin Co. 3. To be completed by the E <br /> <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 />ly. <br />Signature Date 06/19/2024 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />ptZ2L100 213