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SAN J O AQ U I N Environmental Health Department <br /> COUNTY--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections land 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 Chef Hits The Streets Lic. Plate#4TJ6797 <br /> Owner/Operator Name Gary Blanco <br /> Business Mailing Address 295 Bonner Dr <br /> City Tracy State CA Zip95391 Bus. Ph. 5l0 -3 <br /> 1,Gary Blanco 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 r sult in permit <br /> revocation and penaltiesr9 <br /> Signature ll!!//�� Date 7 I 2 Z <br /> 2 To be completed by 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 CA Owner/Operator Cold Storage Commissary, Inc. <br /> Check all appropriate services provided: <br /> p Wastewater disposal 3-compartment sink rd Electrical hook-ups <br /> 0 Solid waste disposal Food preparation if Toilet and handwashing <br /> Id Hot &Cold water for cleaning Store refrigerated food GT Potable water <br /> f� Store dry food/supplies Overnight parking @f 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 hall nou the EHD immediately. <br /> Signature / Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in S V \S�CnUS . 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. ' I <br /> REHS Signature N &,,jW (A Date <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 />