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SAN 10 A Q U I N Environmental Peakh. 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 /> 1. To be completed by APPLICANT <br /> Business Name Primo's Tacos BBQ & Grill Lic. Plate#4SV7831 <br /> Owner/Operator Name Adrian Pineda <br /> Business Mailing Address 1355 S. Wood Ave#A <br /> City Oakdale State CA Zip 95361 Bus. Ph.209-493-7554 Alt. Ph.209-818-7030 <br /> Adrian Pineda , 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 pena ties. <br /> Signature Date �� _ �— - 0 <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 Cold Storage Commissary <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal 2 3-compartment sink s Electrical hook-ups <br /> Solid waste disposal M Food preparation P Toilet and handwashing <br /> "`i Hot& Cold water for cleaning 21 Store refrigerated food Z Potable water <br /> Store dry food/supplies 0 Overnight parking 7 Vehicle wash <br /> 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 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 immediately. <br /> Signature �� �r(h—2 Date <br /> 3. To be completed by the ENV HEALTH/ jurisdiction outside of San Joaquin Co. <br /> The commissary is located in 7 C1�S�-C���S CbJ1� 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. I <br /> REHS Signature (Ati� O,nC,� Date �1 ��1ZG <br /> T <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 />