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SAN JOAQUIN Environmental Health Department <br /> L1,�A_' <br /> —COUNTY-- <br /> cli�V re rr`. <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 ;= t C -�O_ S p0+ Lic. Plate# LA r�P352':4 0� <br /> Owner/Operator Name L_U l S <br /> Business Mailing Address PO (36X �3`l <br /> City _ - 1S_ �tateZip�_Bus. Ph. Z0` -- ;�2-/, S� Alt. Ph. <br /> /��Y�' <br /> I, Ut S k `�C� , 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 enalties. <br /> Signature _ Date 02 2 1 2021 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La Comisaria Modesto FA# 0055437 <br /> Address 1211 S 7th Street Bus. Phone 209-202-5145 <br /> City Modesto Zip 95351 Owner/Operator Manuel Hernandez <br /> Check all appropriate services provided: <br /> Rj Wastewater disposal Cd 3-compartment sink 19 Electrical hook-ups <br /> 0 Solid waste disposal P Food preparation Toilet and handwashing <br /> M Hot & Cold water for cleaning IS Store refrigerated food Potable water <br /> EZ Store dry food/supplies 11 Overnight parking Vehicle wash <br /> I, Manuel Hernandez , 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 C Date 2- <br /> 3. To be completed by the in Co. <br /> ENV HEALTH jurisdiction outside of San Joa u <br /> 1 <br /> The commissary is located in o_i\� 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 theiroperatingpermit changes. <br /> RENS Signature 4 �tk�s 1 I y 3 Date © 1 A 4/2023_ <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 />