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Tot vkTL 90 <br />SAN JOAQUIN Environmental Health Department <br />—C O U N T Y --- <br />RJ <br />Gieotness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility s 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 Jill's Fruit On Top Lic. Plate#4UH6903 <br />Owner/Operator Name Jill R. Macias <br />Business Mailing Address 1400 Divine Ln <br />City Tracy State CA Zip 95376 Bus. Ph. (209) 273-6611 Alt. Ph. (209) 597-7812, <br />i <br />I, V 4 INA 10 k , 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 penaltie <br />r ZX'2�✓ <br />Signature Date <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name La Comisaria Modesto F. <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 />0 Wastewater disposal 3 -compartment sink 0 Electrical hook-ups <br />0 Solid waste disposal ® Food preparation 0 Toilet and handwashing <br />0 Hot & Cold water for cleaning 13 Store refrigerated food ® Potable water <br />0 Store dry food/supplies 13 Overnight parking 0 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 shall notify the EHD immediately. <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in Sta111SIalALS 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 Siqnature J� Date 2I2?, 121)2 <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 />U� <br />