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SA Wd 0 A 0 U I N Environmental Health Department <br /> —COUNTY <br /> Grecmess grows here. <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 /> °.', Ecomleted;b,.,.APP�LICANI, <br /> 1 ,To be, 1.. <br /> Business Name Tacoguacamole Lic.Plate# 'RC1 [3\,/1'�-{_Tl Li✓t�OZCI <br /> Owner/Operator Name Liliana Valencia <br /> Business Mailing Address 1225 Chicago Ave Unit B <br /> City.Modesto State CA Zip 95351 Bus. Ph.209-589-6178 Alt. Ph.209-424-5022 <br /> 1, Liliana Valencia , 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 pen ties. <br /> Signature y _��. 1.� Date <br /> -2' To be corneted b, WMMI,SSARtiY?70__NIR-R/OP,ERAT.ORa <br /> Commissary Name La Comisaria Modesto FA# <br /> Address 1211 S. 7th St. Bus. Phone 209-338-3663 <br /> City Modesto Zip95351 Owner/Operator Cold Storage Commissary Inc. <br /> Check all appropriate services provided: <br /> ® Wastewater disposal 1121 3-compartment sink 0 Electrical hook-ups <br /> ® Solid waste disposal 1Z Food preparation ra Toilet and handwashing <br /> U Hot&Cold water for cleaning m Store refrigerated food U Potable water <br /> 0 Store dry food/supplies 9 Overnight parking 13 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 Califomia 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 own g shall the EHD immediately. <br /> Signature ce Date-09/3 aro <br /> 3,T,o:be com feted:b thgENW(FAL`TH, unsdretion outsidg,ofFSan Joa_ En= <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 Signature Date <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 />