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SANJOAQUIN <br />COUNTY— <br />Greatness 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 />1. To be completed by APPLICANT <br />Business Name Tacos Patino Lic. Plate #4TM5624 <br />Owner/Operator Name Gerrado Patino <br />Business Mailing Address 21948 Blackmore Road <br />City Escalon State CA Zip 95320 Bus. Ph. QQq -,615 - 24 Aft, Ph. <br />Gerrado Patina 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 8 <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 />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 Inc. <br />Check all appropriate services provided <br />® Wastewater disposal 13 3 -compartment sink C21 Electrical hook-ups <br />® Solid waste disposal 13 Food preparation ® Toilet and handwashing <br />® Hot & Cold water for cleaning 19 Store refrigerated food ® Potable water <br />13 Store dry food/supplies 0 Overnight parking G Vehicle wash <br />I, 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 />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. Please notify EHD if the status of their operating permit changes. <br />REHS <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />