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SAN JOAQUIN Environmental HealthjQlLtWp1) <br /> JUL 08 2019 <br /> COMMISSARY AGREEMENT ENVIIZONiNILN-FAL HLALTH <br /> Mobile Food Facility a Caterer 1)E'PA RT.N I L N T <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 Lupitas Cocktail & Food #2 Lic.Plate# 4HU9171 <br /> Owner/Operator Name lose Martin <br /> Business Mailing Address 2844 S Monroe Ave <br /> City Stockton Stated Zipg5206 Bus. Ph.209-401-4651 Alt. Ph. <br /> 1. -)05e A41-4i.o\ , 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 /> revocationnd penalties. <br /> SignatureI C M Q V - -, "\ Date 0-210 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Cold Storage Commissary dba:La Comisaria Modesto FA# <br /> Address 1211 S.7thSt. Bus. Phone Zog- 33%-366 3 <br /> City Modesto Zip 95351 Owner/Operator Claudia Romero <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink ® Electrical hook-ups <br /> 13 Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br /> © Store dry food/supplies rd Overnight parking 13 Vehicle wash <br /> 1, Claudia Romero , 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 owne shall notify the D immediately. <br /> Signature /�i�"""`— Date <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 /> 186 E. azelron Avenue I Stockton. California 9505 1 T 209 4C8-3420 F 20c 464-0138 1 vfA1v,.sjgov.crg'ehd <br />