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. i <br /> SAN J U A Q U I N Environmental Health Department <br /> `.— COUI`ITY - <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 9 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 Mis Tres Pollos Lic. Plate#4SU7859 <br /> Owner/Operator Name Rosa Gonzalez <br /> Business Mailing Address 2878 Don Rafael Ave <br /> City Riverbank State CA Zip 95367 Bus. Ph.209-450-3460 Alt. Ph.209-200-2390 <br /> Rosa Gonzalez 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. n <br /> Signature�� L``�yY� 1�7� Date_.lb -�0 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> i <br /> iCommissary 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 /> ® Wastewater disposal 0 3-compartment sink 0 Electrical hook-ups <br /> ® Solid waste disposal ® Food preparation Q Toilet and handwashing <br /> ® Hot& Cold water for cleaning M Store refrigerated food 10 Potable water <br /> G3 Store dry food/supplies 0 Overnight parking M 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 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 m> /v Date 06119/'�Lo <br /> 3. To be completed by the ENV,HEALTH jurisdiction outside of San Joaquin Co.. <br /> The commissary is located in `S' 4r�'1 �44� 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, j <br /> c� I <br /> REHS Signature i Date J/�--�e Zo <br /> 1868 E. Hazelton Avenue I Stockton,California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br /> i <br />