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- = SA NUJ QAQ U I N Environmental Health Department <br /> COUNTY <br /> _�- <br /> _`F�.' Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Complete sections i 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 r 104'-' S QO+ Lic. Plate# °I <br /> Owner/Operator Name I--U l S /�',,rfyy"nd0 <br /> Business Mailing Address PO 130Y Say <br /> City WQS-�1-t� State_CLZip953P)-Bus. Ph.ZO`1-�_42-6 i S6 Alt. Ph. <br /> I, L— j�S Nr �� reZ , 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. <br /> Signature�r7� Date C)2 -21-1 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 /> R, Wastewater disposal C 3-compartment sink 19 Electrical hook-ups <br /> a Solid waste disposal Food preparation 11 Toilet and handwashing <br /> M Hot & Cold water for cleaning IS Store refrigerated food Potable water <br /> Store dry food/supplies a Overnight parking Vehicle wash <br /> l 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 /> - <br /> Signature Z"-ZllA Date z- z9 z7 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in S l'&. 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 /> REHS Signature Rtes 1Iy Date 01 A:['/2021 <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 1 T 209468-34201 F 209464-0138 lwww.sjgov.org/ehd <br />