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SANJOAQUIN Environmental Health Department <br />COUNTY <br />Greatness grows here. <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 Central Valley Hospitality Group LLC Lic. Plate#252V59 <br />Owner/Operator Name Revathi Yellanti <br />Business Mailing Address 368 E Angelina Ave <br />City Mountain House State CA Zip 95391 Bus. Ph. (508) 287-9860 Alt. Ph. <br />I, Revathi Yellanti , 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 OWNEMPERATOR <br />Commissary Name La Comisaria Modesto <br />1211 S. 7th Street Bus. Phone (209) 338-3663 <br />City Modesto Zip 95351 Owner/Operator Cold Storage Commissary, Inc. <br />Check all appropriate services provided: <br />0 Wastewater disposal 0 3 -compartment sink ® Electrical hook-ups <br />0 Solid waste disposal ld Food preparation 0 Toilet and handwashing <br />Ef Hot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br />YJ Store dry food/supplies 0 Overnight parking 0 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 />Signature,Date 10/03&z <br />3. To be completed. by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br />The commissary is located in 51111AWIdue 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 209 466-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />