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SAN OAQ U I N Environmental Health Department <br /> _ BOUNTY -- <br /> q ' 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_ Ln (c)Ci,) +ca 1 1�i7 a Lic. Plate# '1 R1�g05 <br /> Owner/Operator Name Ana /`iGr"r-, Pogcvla <br /> Business Mailing Address P,101 Vid <br /> City tcLA State Cly Zip t Bus. Ph. tQ) Alt. Ph. <br /> 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 /> /� Z <br /> Signature ✓/`dC�Gv- Date <br /> 61 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName La omigaria Modesto —FA# <br /> Address 1211 S 7th Street _Bus. Phone(209) 202-5145 <br /> City Modesto Zip 95351 Owner/Operator Cold Storage Commissary, Inc. <br /> Check all appropriate services provided: <br /> ® Wastewater disposal J 3-compartment sink 0 Electrical hook-ups <br /> 0 Solid waste disposal W Food preparation 13 Toilet and handwashing <br /> * Hot & Cold water for cleaning Q Store refrigerated food Q Potable water <br /> * Store dry food/supplies Q Overnight parking (3 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 own/err shall notify the EHD immediately. <br /> Signature NL4_'�� <br /> Dae - <br /> 3. To be completed b the ENV HEALTH jurisdiction outside llof_San Joa uin Co. <br /> The commissary is located in A(A V\�1 S VCAV 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. Ple otify EHD if the status of their operating permit changes. <br /> REHS Signature 6j Date Z <br /> C2c?'-A) szs-G-3 3 3 <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 />