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SAN JOAQUIN <br />C(''JNTY - <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 Los Primos Tex-Mex Food Lic. Plate#4UB4370 <br />Owner/Operator Name Armando Carbajal <br />Business Mailing Address 321 Granada Way <br />I <br />CityTracy State CA Zip 95367 Bus. Ph. 209-362-9123 Alt. Ph. <br />1, Armando Carbajal , 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 />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 />0 Wastewater disposal 0 3 -compartment sink M Electrical hook-ups <br />0 Solid wasje disposal 0 Food preparation ® Toilet and handwashing <br />El Hot & Cold water for cleaning M Store refrigerated food 0 Potable water <br />0 Store dry food/supplies 0 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 ownershallshall notify the EHD immediately. <br />Signature Date YZ-M ?_ <br />3. To be completed by the ENV HEALTH iurisdiction outside of San Joaquin 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 Signature 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 />