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SAN JOAQUIN Environmental Health Department <br />—COUNITY— <br />.. Greotn,56 growc here <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ,L 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 EI Gato Volado Lic. Plate # 4SV2622 <br />Owner/Operator Name Luis N Martinez <br />Business Mailing Address 21435 S Corral Hollow Road <br />City Tracy State CA Zip95304 Bus. Ph. (209) 814-4278 Alt. Ph. <br />1 Luis N Martinez , 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 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name La Comisaria Modesto FA# <br />ress 1211 S. 7th Street Bus. Phone (209) 338-3663 <br />Modesto Zip95351 Owner/Operator Cold Storage Commissary, Inc. <br />Check all appropriate services provided <br />p Wastewater disposal 111 3 -compartment sink V Electrical hook-ups <br />® Solid waste disposal 119 Food preparation IY Toilet and handwashing <br />Ef Hot & Cold water for cleaning Ef Store refrigerated food Qf Potable water <br />Ef Store dry food/supplies a Overnight parking d 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 />3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br />The commissary is located in 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 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />