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SAN JOAQuIN <br /> <br />Environmental Health Department <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 />To be completed by APPLICANT <br />Business Name Taqueria El Rey LLC <br />Owner/Operator Name Fuentes Canchola Reynaldo <br />Business Mailing Address 2109 Claymont Dr <br />City Modesto State CA Zip 95350 Bus. Ph. 95350 <br /> <br />Lic. Plate #35510L2 <br /> <br />Alt. Ph. <br /> <br />I, 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 />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name La Comisaria Modesto <br />Address 1211 S. 7th St. <br /> <br />FA# <br />Bus. Phone 209-338-3663 <br />City Modesto <br /> <br />Zip 95351 <br /> <br />Owner/Operator Mark Luis-Cruz <br /> <br />Check all appropriate services provided: <br />Wastewater disposal <br /> a 3-compartment sink <br /> <br />GI Electrical hook-ups <br />Solid waste disposal <br /> <br />El Food preparation G Toilet and handwashing <br />El Hot & Cold water for cleaning <br />L Store refrigerated food <br /> <br />Ei Potable water <br />E21 Store dry food/supplies Ea Overnight parking O Vehicle wash <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 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 notify the EHD immediately. <br />ALL <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. P e-Ret _ .P if the status of their operating permit changes. <br />REHS Signature Date 3 - /i <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I vvww.sjgov.org/ehd <br />1, Mark Luis-Cruz <br />Signature Date 03 i I ?cZ)