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SAN JOAQUIN Environmental Health Department <br /> COUNTV - <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 Tacos La Cochinita Lic. Plate#4TZ8148 <br /> Owner/Operator Name Anna Bejarano Garcia <br /> Business Mailing Address 510 Czerny St <br /> City Tracy State CA Zip95304 Bus. Ph.209-771-6399 Alt. Ph. <br /> ,,Anna Bejarano Garcia , 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 penalties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La Comisaria Modesto FA# <br /> Address 1211 S. 7th Street Bus. Phone 209-338-3663 <br /> City Modesto Zip CA Owner/Operator Cold Storage Commissary, Inc. <br /> Check all appropriate services provided: <br /> ® Wastewater disposal Ed 3-compartment sink 6Y Electrical hook-ups <br /> 0 Solid waste disposal WFood preparation E�Toilet and handwashing <br /> ,Q! Hot& Cold water for cleaning (d Store refrigerated food td Potable water <br /> Ul Store dry food/supplies 11 Overnight parking i2f 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 ���f� �"� - Date ,3/3I/2a <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in `1'Jt� 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 .Lv' � Date 3/3i/Zo:22., <br /> 1868 E. Hazelton Avenue j Stockton; California 95205 j T 209 468-3420 1 F 209 464-0138 1 mvw.sjgov.org/ehd <br />