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SANJOAQUIN <br />COUNTY— <br />Greatness grows her <br />Environmental Health Department <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 />Owner/Operator Name Jill R. Macias <br />Business Mailing Address 1400 Divine Ln <br />City Tracy a. State CA Zip 95376 Bus. Ph. (209) 273-6611 Alt. Ph. (209) 597-781 <br />(-fit\ t\A [RAZ 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 />Signature Date - z <br />2. 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 />Lic. Plate # 4UH6903 Business Name Jill's Fruit On Top <br />Wastewater disposal <br />Solid waste disposal <br />la Hot & Cold water for cleaning <br />Er Store dry food/supplies <br />121 3-compartment sink <br />0 Food preparation <br />0 Store refrigerated food <br />Ca Overnight parking <br />V Electrical hook-ups <br />V. Toilet and handwashing <br />V Potable water <br />V 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 shall notify the EHD immediately. <br />r , Signature <br /> <br />Date 0,2/g <S7;23 <br /> <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in S'3Y\ \ \.)„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 />1, Mark Luis Cruz <br />REHS Signature <br /> <br />Date 2.12g. 2D2.. 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