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SANJOAQUIN <br />COUNTY <br />Greatness grows her <br />Environmental Health Department <br />F-460243).2_ <br />Fozo544. 4 36 <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 />To be completed by APPLICANT <br />Business Name 7----70YCLAct3' [)-"tt/ia. # 2 <br /> <br />Lic. Plate # C"( n 3L. 2- <br /> <br />Owner/Operator Name (305Q_ - Het, V1a.1 d e <br />Business Mailing Address 2.0 ))0 6 rCA- ,S017 Rd # 2 c1 <br />City cere StateC4 Zip 763o Bus. Ph. 207— '(7 -552 ) Alt. Ph. <br />Osct f-te et,/i , 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 les. <br />Signature Date 00 — Of - <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name La Comisaria Modesto FA# <br />Address 1211 S. 7th Street <br />City Modesto Zip 95351 <br />Check all appropriate services provided: <br /> <br />Bus. Phone (209) 338-3663 <br /> <br />Owner/Operator Cold Storage Commissary, Inc. <br /> <br />Wastewater disposal <br /> <br />3 3-compartment sink <br /> <br />3 Electrical hook-ups <br />Solid waste disposal <br /> <br />3 Food preparation <br /> V Toilet and handwashing <br />0 Hot & Cold water for cleaning <br /> <br />3 Store refrigerated food <br /> <br />V Potable water <br />cr Store dry food/supplies <br /> 3 Overnight parking 3 Vehicle wash <br />, 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 II notify the EHD immediately. <br />Signature • <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in9—fr- cux. 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 />I, Mark Luis Cruz <br /> <br />Date /▪ ,/,-, <br />rc, <br /> <br />RENS Signatur= jb,,APAN II 0 .1 Date <br />au.s49 /4/3 - <br /> <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd