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Environmental Health Department <br /> S A N �J O A Q U I N <br /> —COUNTY <br /> cg ` 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 Tobecotn letetl�b'`' APPLICANT <br /> Business Name Floyd;`IpcS D:z.(rcc 2 Lic. Plate# 9(0 yj 3'L 2 <br /> Owner/Operator Name 605a - He v ✓)ctrl QIp Z <br /> Business Mailing Address_ 2 o 3o Tc-5� r) rc-YSv;� Pol <br /> City Ces S StateC4_Zip o Bus. Ph. 709- $l T-53 0 Alt. Ph. <br /> 1, <br /> 05a H2✓-i an rIP Z 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 pen ,es. <br /> v <br /> Signature - Date <br /> 7"-Z <br /> ll <br /> ' 2 To,lie�'coni' �'letedib'"�C®M`MI>S^SARY�®` N�Ef�O`�F�E�R�ATO'R �• , '•'- , <br /> Commissary Name _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 /> ® Wastewater disposal Gi 3-compartment sink 0 Electrical hook-ups <br /> ® Solid waste disposal 13 Food preparation 0 Toilet and handwashing <br /> 0 Hot& Cold water for cleaning 0 Store refrigerated food 13 Potable water <br /> 13 Store dry food/supplies M Overnight parking (3 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 sh I notify the EHD immediately. <br /> Signature -- Date <br /> 3. To be'com "Letetl`'b:°)the ENV HEAL'THt ursdlctlo••n outslde,'of,Sa'n bin Co. <br /> The commissary is located in ) b-'VA a-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 Signatureo 00 J Date - 2( - ;Z-D 2-3 <br /> U L9-.- c D, Irv.o Uk- ra:*Sro/q', <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />