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OP(]VI•: <br /> SAN SJOAQUIN Environmental Health Department <br /> i_i; <br /> —COUNTY—Greatnes=s grows here. <br /> .,a <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 EI Gato Volado Lic. Plate#4SV2622 <br /> Owner/Operator Name Luis N Martinez <br /> Business Mailing Address 21435 S Corral Hollow Road <br /> City Tracy State CA Zip 95304 Bus. Ph. (209) 814-4278 Alt. Ph. <br /> 1, LUIS N Martinez , 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 Slee permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and nalti <br /> Signature Date / Z /G/-Z e, Zt <br /> 2. To be com feted by COMMISSARY OWNEMPERATOR <br /> Commissary Name La Comisaria Modesto FA# <br /> Address 1211 S. 7th Street Bus. Phone(209) 338-3663 <br /> City Modesto Zip95351 Owner/Operator Cold Storage Commissary, Inc. <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal Ir 3-compartment sink Electrical hook-ups <br /> 0 Solid waste disposal 19 Food preparation D'Toilet and handwashing <br /> U Hot & Cold water for cleaning Et Store refrigerated food U Potable water <br /> Ef Store dry food/supplies EX Overnight parking El 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 /> Signature Date /z�1 2I <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />