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p�os3dZzz <br /> SAN€f Q A Q U I N Environmental Health Department <br /> _ y —COUNTY— <br /> ,,,:,,;>=' Greatness grows here. <br /> I <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s Caterer <br /> Complete sections f and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name Antojitos La Morenita Lic. Plate#4PM4141 <br /> Owner/Operator Name Maria Guadalupe Barron <br /> Business Mailing Address 140 E. Jefferson Street <br /> City Stockton State CA Zip 95206 Bus. Ph. Alt. Ph. <br /> I,Marla Guadalupe Barron 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 tties. <br /> Signatu Date <br /> 2 �o be com .`" Ieteb ®MMISSARYOWNE,R/®,PERATOR ? " '„_„. <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 Inc. <br /> Check all appropriate services provided: <br /> ® Wastewater disposal 16 3-compartment sink 0 Electrical hook-ups <br /> ® Solid waste disposal 19 Food preparation (21 Toilet and handwashing <br /> Ef Hot&Cold water for cleaning d Store refrigerated food 1Z Potable water <br /> U Store dry food/supplies 61 Overnight parking GYVehicle wash <br /> 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 B Date /.2—2—a p <br /> 3 Tobe corT� l!3-dib th E V` FIETALTH urisd ctlon outsid_e�of Sap, 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />