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SANdOAQUIN Environmental Health Department <br /> —COUNTY <br /> Grearness grog, 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 completedby APPLICANT <br /> Business Name No Que No Lic. Plate#8P38708 <br /> Owner/Operator Name Nora Beatriz Perez <br /> Business Mailing Address 1672 Vivian Road <br /> City Modesto State CA Zip 95358 Bus. Ph.209-486-2339 Alt. Ph. <br /> Nora Beatriz Perez 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 andpenaltie <br /> Signature ��11�— Date <br /> 2. To be completedby COMMISSARY OWNER/OPERATOR <br /> Commissary Name La Comisaria Modesto FA# <br /> Address 1211 S.7th Street Bus. Phone 209-338-3663 <br /> City Modesto Zip 95351 Owner/Operator La Comisaria Modesto <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal C1 3-compartment sink 19 Electrical hook-ups <br /> ® Solid waste disposal Food preparation 0 Toilet and handwashing <br /> IPJ Hot& Cold water for cleaning 0 Store refrigerated food U Potable water <br /> IZ Store dry food/supplies IZ Overnight parking 13 Vehicle wash <br /> 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 y-/Z- Z 1 <br /> 3. To be completed by the=ENV HEALTH-'urisdiction outside of San J oag uin Co: <br /> The commissary is located in 5k-rAyI-isl o,US 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 A- F'-o>fm LGI Date 04/1q /ZOZI <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 />