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C Z <br /> SAN JOAQUIN Environmental Health Department <br /> --COUNTY— <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 Comal Coffee Lic. Plate#4RD9329 <br /> Owner/Operator Name Zovla Cifuentes <br /> Business Mailing Address 710 Chaaall Lane <br /> City Stockton State CA Zip 95209 Bus. Ph.(925)478-9678 Alt. Ph. <br /> I, G NkVAA-e3 hereby state that the above information is current, true and correct to <br /> the bes 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 /> Date a 013 - <br /> Signature arJa 3 <br /> 2. To be com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary NamFA# <br /> AddresBus. Phone(209) 338-3663 <br /> City Modesto Zip 95351 _Owner/Operator Cold Storage Commissary. lnc <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal td 3-compartment sink V Electrical hook-ups <br /> 0 Solid waste disposal 0 Food preparation IZ Toilet and handwashing <br /> m Hot&Cold water for cleaning 61 Store refrigerated food 12 Potable water <br /> 0 Store dry food/supplies la Overnight parking 0 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 Califomia 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 ' � DateZ3/Z3 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in , Is 16-b-, 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 Signatur �� 1 Date Z-Z3 - 2023 <br /> 1868 E. Hazelton Avenue i Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd / <br />