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SAN-JOQQUIN Environmental Health Department <br /> fS —COU NTY <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 completed bAPPLICANT", <br /> Business Name Lupita's Cocktails Estilo Junior Lic. Plate#4U B4545 <br /> Owner/Operator Name Abel Nemecio Martin <br /> Business Mailing Address 2844 S Monroe St <br /> City Stockton State CA Zip 95206 Bus. Ph. (209) 484-8470 Alt. Ph, <br /> 1 Abel Nemecio Martin , 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_ /J ilo+ruiZ�" Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La Comisaria Modesto FA#N/A <br /> Address 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 /> ® Wastewater disposal 0 3-compartment sink E3 Electrical hook-ups <br /> ® Solid waste disposal H Food preparation 3 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning @ Store refrigerated food 13 Potable water <br /> 13 Store dry food/supplies © Overnight parking m 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 owner shall notify the EHD immediately. <br /> Signature Date �//off/2z <br /> 3. To be completed by the ENV HEALTH jurisdiction outside <br /> uurissdiction'outside of San Joa uin Co.: <br /> The commissary is located in ti 6 04 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 HD if �he status of their operating permit changes. <br /> Y— l� <br /> REHS Signature �'" I Date (7 (0102-2-- <br /> L i <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 />