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SAN JOAQUIN <br />-- CGNNTY --- <br />Environmental Health Department <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 Chef Hits The Streets <br />Owner/Operator Name Gary Blanco <br />Business Mailing <br />295 Bonner Dr <br />Plate # 4TJ6797 <br />City Tracy State CA Zip95391 Bus. Ph. 510-3 �,3 4 M:fph. <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 suit in permit <br />revocation and penalties7 I <br />Signature <br />�� Date r 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_ A Owner/Operator Cold Storage Commissary, Inc. <br />Check all appropriate services provided: <br />0 Wastewater disposal ef 3 -compartment sink QI Electrical hook-ups <br />0 Solid waste disposal 9 Food preparation Ef Toilet and handwashing <br />Hot & Cold water for cleaning 0 Store refrigerated food Cr Potable water <br />Store dry food/supplies Overnight parking l( vehicle wash <br />1 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 ow�nner hall noti the EHD immediately. <br />Rin nnfi irp //� —Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in SVUV�tSVAVS . 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />