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i <br /> i <br /> SANJOAQUIN Environmental,, Heakh D)Lp artomeont <br /> - -COUNTY-- <br /> COMMPSSARY 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 /> To be;corn leted}b .APPLICANT j <br /> Business Name Mis Tres Pollos Lic.Plate#4SU7859 <br /> Owner/Operator Name Rosa Gonzalez <br /> Business Mailing Address 2878 Don Rafael Ave <br /> City Riverbank State CA Zip 95367 Bus. Ph.209-450-3460 Alt. Ph.209-200-2390 <br /> 1,Rosa Gonzalez hereby state that the above information is current,true and correct tc <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. 1 /1 <br /> Signature L (ACJV�? atII2-2, Date 6 48 -120 <br /> 2. To be com' leted by COMMISSARY OWNERIOPERATOR <br /> Commissary Name La Comisaria Modesto FA# <br /> Address 1211 S 7th St. Bus. Phone 209-338-3663 <br /> City Modesto Zip 95351 owner/operator Cold Storage Commissary <br /> i <br /> Check all appropriate services provided: <br /> ® Wastewater disposal M 3-compartment sink 13 Electrical hook-ups <br /> ® Solid waste disposal 0 Food preparation ® Toilet and handwashing <br /> ® Hot&Cold water for cleaning ® Store refrigerated food ® Potable water <br /> 0 Store dry food/supplies ® Overnight parking m Vehicle wash <br /> I <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 shallnotifythe EHD immediately. <br /> Signature f Date C61I191d-o <br /> ;3::,,To-:!W667n fet0.506 !.ENVHEALTH; ti`risdlcfion;putsldefof San,Joa uimaCo. . <br /> The commissary is located in S�a�+f�4l�� 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 /> REHSSignature_ r�<-g//pr�yi!c/i' Date 6/�///—.?0 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />