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SAN JOAQUIN <br />COUNTY <br />Greatness grows he , <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 />Business Name 56 De. Pexlc <br />Owner/Operator Name Al cr6. orv-5 HoeceeQ4 <br />Business Mailing Address 2-la u-)e-A- CloJer gd <br /> <br />Lic. Plate# <br /> <br />City --TreA04 StateC,A Zip 'NS-7-G Bus. Ph. c-z.0,-01(, Alt. Ph. iru <br />I, 4/Erato F(cires (4ijereck, 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 pe <br />Date Signature <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 />Wastewater disposal <br /> <br />3-compartment sink <br /> <br />1,3 Electrical hook-ups <br />Solid waste disposal <br /> <br />IZ Food preparation <br /> Pr Toilet and handwashing <br />Hot & Cold water for cleaning <br /> i21 Store refrigerated food <br /> <br />Cif Potable water <br />Store dry food/supplies Overnight parking <br /> (21 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 />Signature <br /> <br />Date 02/OVA 5 <br /> <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 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 Signature Date <br />1868 E. Hazelton Avenue Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />I, Mark Luis Cruz