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SAN JOAQUIN Environmental Health Department <br /> i, COU NTY— <br /> "c,FoE,= 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 Comal Coffee Lic. Plate#4RD9329 <br /> Owner/Operator Name Zo la Cifuentes <br /> Business Mailing Address 710 Cha all Lane <br /> City Stockton State CA Zip 95209 Bus. Ph.(925)478-9678 Alt. Ph. <br /> I, G Q� 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 /> Signature <br /> Date a IV - <br /> 12. <br /> 3 -2. To be com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La Comicaria Modesto FA# <br /> Address 1211 S 7th Street Bus. Phone(209) 338-3663 <br /> City Zip 95351 Owner/Operator Cold Storage Commissary, Inc. <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal [a 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 19 Store refrigerated food @ Potable water <br /> 0 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 OZT3/23 <br /> 3. To be com leted b th`e ENVHEALTH 'urisdiction outside of San Joa uin Co. <br /> The commissary is located in 1(l'U-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 Signatur 61 Date_ Z-23 - 2o03 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209.468-3420 1 F 209 464-0138 1 www.Sjgov.org/ehd <br />