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i, SANsJOAQUIN Environmental Health Department <br />LT".A'` —COUNTY— <br />9 <br />Greatness rows here. <br />. qty°aim <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1> 1TO�be cQial letedb`/ �rI�� .Vf FAl1 F{f1M:.ia :. .t IYWAr. <br />�1 <br />Business Name 2 Lic. Plate# q 17 <br />Owner/Operator Name fi OSa. He v ✓7ccr7 * z <br />Business Mailing Address 20 30 Ta5�- (,; rca­ d S_L 2 a <br />City CCAS State%0L Bus. Ph. 709- 8ffi'-S3So Alt. Ph <br />Zip � <br />1, pt 05ct gf-Yi an d 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 />Commissary Name La Comisaria Modesto FA# <br />Address -211 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 E9 3. -compartment sink I3 Electrical hook-ups <br />® Solid waste disposal 13 Food preparation 13 Toilet and handwashing <br />Hot & Cold water for cleaning lug Store refrigerated food 13 Potable water <br />13 Store dry food/supplies id 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 shgl�notify the EHD immediately. <br />The commissary is located in ki+(y N � S I Cut 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 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />