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SAN JOAQUIN Environmental Health Department <br /> COUNTY <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 EI Gordo Jay Lic. Plate#4TD7514 <br /> Owner/Operator Name Margarita Sanchez <br /> Business Mailing Address 2215 Tahoe Timber Way <br /> City Riverbank State CA Zip 95367 Bus. Ph. Alt. Ph. (209)681-2040 <br /> I, Patino Sanchez , 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 Date 3-11-21 <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 /> 0 Wastewater disposal m 3-compartment sink 0 Electrical hook-ups <br /> p Solid waste disposal 1Z Food preparation 0 Toilet and handwashing <br /> Cd Hot &Cold water for cleaning 19 Store refrigerated food 13 Potable water <br /> Elf Store dry food/supplies M Overnight parking 0 Vehicle wash <br /> I, Alfonso Meraz , hereby state that the information I have provided <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirement Stan' i <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modifie ' <br /> commissary owner shall notify t HD immediately. <br /> Signature Date <br /> r my <br /> 3. To be completed by the ENV HEALTti jurisdiction outside of San <br /> �n JENNIFER HEREDIA- <br /> The commissaryIs located In 1 noun . The above fool HERNANDEZ p <br /> ty. Environmental Health Specialist <br /> commissary requirements in California Health & Safety Code. T above checked services t ENVIRONMENTAL RESOURCES <br /> above commissary. Please notify EHD if the status of their operatin permit changes. Environmental Health Division <br /> 3800 Cornucopia Way,Suite'c <br /> REHS Signature Date I Modesto,CA95358-9494 I <br /> Direct(209)525-6791 I <br /> Main:(209)525-6700 <br /> 1868 E. Hazelton A e ue I Stockton, California5205 209 468-3420 1 F 209 464-0138 11 Cell:(209)278-5369 <br /> Fax:(209)525-6774 <br /> Email:jhernandez@envres.org <br /> www stancounty cow <br />