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A U I N Environmental Health Department <br /> SAN 10 Q <br /> COUNTY <br /> GreoEness grovr. <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 complete b -APPLICANT <br /> Mel 's Churros#7 Lic. Plate# <br /> Business Name y <br /> Owner/Operator Name <br /> Business Mailing Address <br /> � <br /> - Z, Bus. Ph. Alt. Ph. <br /> , hereby state that the above information is current, <br /> it ,I <br /> City StatejjZiprj true and correct to <br /> knowled a a�agreeze my approved commissary in accordance with California Health & <br /> the best of my 9 <br /> ti the EHD. Failure to notify this office may result in permit <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use o the <br /> commissary is discontinued, the permit holder must fy <br /> revocation and pe Ities. � ` Date _6 <br /> Signature `" �s� ` ` <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Kitchen LLC FA# <br /> Max's <br /> Commissary Name <br /> Address Z0g 338-3663 <br /> 1211 S. 7th Street Bus. Phone <br /> City <br /> Modesto Zip 95351 Owner/Operator William Birkowitz <br /> Check all appropriate services provided: ® Electrical hook-ups <br /> 0 Wastewater disposal 14 <br /> 3-compartment sink <br /> Ef <br /> Food preparation Toilet and handwashing <br /> 0 Solid waste disposal [g( Potable water <br /> d Hot & Cold water for cleaning N4 Store refrigerated food 16 Vehicle wash <br /> Store dry <br /> food/supplies ✓ Overnight parking <br /> Mark Luis Cruz , hereby state that the information I have provided is current. true and <br /> rements. if <br /> o the best of my knowledgeand meets the California Health&Safety <br /> s agreement islm modified orthe cancelllfacility <br /> led, the <br /> correct t , of this agreement, or if t 9 <br /> operator fails to comply with the conditions <br /> commissary owner shall notify the EHD immediately. Date f0 `6 -Z3 <br /> Signature <br /> To be completed b the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> 3 County. The above food facility meets the <br /> The commissary is located in <br /> Health & Safety o services are available at the <br /> commissary requirements in California <br /> above commissary. Please notify EHD if the status oftheirerat ng permit changes <br /> p <br /> Date <br />