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SANrJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Ar Greatness 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 /> 1. To be completed b 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 Zip95367 Bus. Ph. Alt. Ph.(209)681-2040 <br /> I.Patlno 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 OWNEWPERATOR <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 121 3-compartment sink IM Electrical hook-ups <br /> ® Solid waste disposal ® Food preparation ® Toilet and handwashing <br /> 12 Hot&Cold water for cleaning 19 Store refrigerated food d Potable water <br /> 13 Store dry food/supplies ® .Overnight parking ® Vehicle wash <br /> 1, Alfonso Meraz ' hereby state that the information I have provided <br /> orA <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirement: S�OQ% r <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modifierifflty commissary owner shall notify t HD immediately. <br /> Signature Date 3'�� <br /> G <br /> 3. To be completed-by the ENV HEALTH jurisdiction outside of San! <br /> , JENNIFER HEREDIA- <br /> The commissa is located In noun . The above foo( HERNANDEZ <br /> ry ty Environmental Health Specialist <br /> commissary requirements in California Health & Safety Code. T above checked services E ENVIRONMENTAL RESOURCES <br /> above commissary. Please notify EHD if the status of their operatin permit changes. Environmental Health Div/' ' n <br /> 3800 Comucopia Way,Suite9C <br /> REHS Signature Date I Modesto,CA 95358-9494 <br /> Direct:(209)525-6791 <br /> Main:(209)525-6700 <br /> 1868 E. Hazelton A e ue I Stockton, Califomia5205 209 468-3420 1 F 209 464-0138 Cell:(209)278-5369 <br /> Fax:(209)525-6774 <br /> Email:jhernandez@envres.org <br /> w stancounty mm <br /> • : <br />