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SANJOAQUIN Environmental Health Department <br /> lst,tfi '. --COUNT Y- <br /> 4; ° 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 Las Mexicanas Lic. Plate#51922C3 <br /> Owner/Operator Name Lourdes Salazar <br /> Business Mailing Address 2480 S Madison St <br /> City Stockton State CA Zip 95206 Bus. Ph. (415) 946-9490 Alt. Ph. <br /> �, <br /> I, ni )✓PAr3:1 C7 G cccu 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 Pzunty Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalti <br /> Signature Date_Z9Z 23 <br /> r• <br /> be co le ed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName La Comisaria Modesto FA# <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 /> 0 Wastewater disposal 0 3-compartment sink 0 Electrical hook-ups <br /> 0 Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br /> U Store dry food/supplies 0 Overnight parking 0 Vehicle wash <br /> I, 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 N�I�/,23 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in 90,ol & lou S 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 />