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2 Z <br /> SAN JOAQUIN Environmental Health Department <br /> ---C OUNITY — <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 Antojitos La Morenita Lic. Plate#4PM4141 <br /> Owner/Operator Name Maria Guadalupe Barron <br /> Business Mailing Address 140 E. Jefferson Street <br /> City Stockton State CA Zip 95206 Bus. Ph. Alt. Ph. <br /> I, Maria Guadalupe Barron 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 andpe ties. + <br /> Signature/ Date <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 Zip95351 owner/Operator Cold Storage Commissary Inc. <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal m 3-compartment sink 0 Electrical hook-ups <br /> 0 Solid waste disposal 121 Food preparation 0 Toilet and handwashing <br /> Ef Hot & Cold water for cleaning LI Store refrigerated food IZ Potable water <br /> 0 Store dry food/supplies lad Overnight parking O/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 /> Signature Date /.2—2 —D-o <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 Signature Date <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 i T 209 468-3420 i F 209 464-0138 i www.sjgov.org/ehd <br /> S <br />