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SAN JUAOUIN EnvironmentM Health Depailfnerit <br /> COUNTY______ <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 Taqueria EI Rey LLC Lic, Plate#35510L2 <br /> Owner/Operator Name Fuentes Canchola Reynaldo <br /> Business Mailing Address 2109 Claymont Dr <br /> City Modesto State CA Zip 95350 Bus. Ph. 95350 Alt. Ph. <br /> 1 Fuentes Canchola Reynaldo , 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 La Comisaria Modesto FA# <br /> Address 1211 S. 7th St. Bus. Phone 209-338-3663 <br /> City Modesto Zip 95351 Owner/Operator Mark Luis-Cruz <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal 3-compartment sink U,; Electrical hook-ups <br /> Solid waste disposal 0 Food preparation R. Toilet and handwashing <br /> * Hot&Cold water for cleaning E9 Store refrigerated food R Potable water <br /> 01 Store dry food/supplies tq Overnight parking 91 Vehicle wash <br /> 1, Mark Luis-Cruz , 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 fpod 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 <br /> shall notify the EHD immediately. <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH 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.&Pe-notify-E-1if the status of their operating permit changes. <br /> 1171-11) <br /> RENS Signature -- Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 E 209 464-0138 1 www.sjgov.org/ehd <br />