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SANSJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be corn i leted by APPLICANT <br /> Business Name Por-44 Agoz Frescos Lic.Plate# yV13g51g <br /> Owner/OperatorNameRnnre5 <br /> Business Mailing Address '6160 Cceme Moet/ <br /> Cityr-ookda�. State CA Zipg5361 Bus. Ph. (a?0q)8oq-"05 —Alt. Ph. <br /> I, 6x In_vanlis �vneps 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�Cx 0 UC VI 1 G �/ Date <br /> 2. To be cam leted ti 103,0 15_SARY OWRERLOPERAT�OR <br /> CommissaryName La (^Om sor iA Afoele.5�0 FA# <br /> Address (a 11 �j �+" 54reea- Bus. Phone Ca09)3346-366 3 <br /> City.1.4 odes-Fn Zip 45351 Owner/Operator Cola/ 54vraue /i nr%s �.wt.Inc <br /> Check all appropriate services provided: <br /> 13 Wastewater disposal ® 3-compartment sink 13 Electrical hook-ups <br /> M Solid waste disposal I3 Food preparation 13 Toilet and handwashing <br /> Ca Hot & Cold water for cleaning ® Store refrigerated food 13 Potable water <br /> 0 Store dry food/supplies 10 Overnight parking 13 Vehicle wash <br /> I, Mark Lv i5 Cru? hereby state that the information 1 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 W&d2i1� Date 101aolaa <br /> 3. To be,com leted by the ENV HEALTH jurisdiction outsideQf San Joa'uin Co. <br /> The commissary is located in &Oxifi(11166 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 AC- aAa �� Date I O(1�f 907 Z <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 />