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PQ 0 SO Wt o <br /> S thiN 1 0 AQ U I N Environmental Health Department_ <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 La Toxica <br /> Lic.Plate#91629R3 <br /> Owner/Operator Name Juan Miniares <br /> Business Mailing Address 2709 Parkdale Dr <br /> City Modesto �� p _ �_ 209 771-7471 Alt. Ph. <br /> State Zi A53. 8 Bus. Ph. <br /> information is current,true and correct to <br /> I ,hereby state that the above <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. Date <br /> Signature <br /> 2.To be com leted b COMMISSARY OWNERIOPERATOR <br /> Max's Kitchen LLC FA# <br /> Commissary Name 209 338-3663 <br /> Bus.Phone� <br /> Address 1211 S. 7th Street William Berkowitz <br /> City Modesto Zip 95351 Owner/Operator <br /> services provided: <br /> Check all appropriateartment sink ® Electrical hook-ups <br /> 0 3-comp <br /> 0 Wastewater disposal ❑ Food preparation ® Toilet and handwashing <br /> m„ 0 Solid waste disposal 0 Potable water <br /> Cold water for cleaning Lg Vehicle wash <br /> {3 Hot&Co ❑ Store refrigerated food <br /> C3 Store dry food/supplies <br /> (j Ovemight parking <br /> hereby state that the information I have provided is current,true and <br /> v;s C e and meets the California Health&Safety Code requirements. If the food facility <br /> ' Ar knowledg <br /> IARe�t the est of my with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> operator fails to Comply <br /> the EHD immediately. <br /> commissary ow shall notify _� Date <br /> Signature — -- U <br /> b the ENV HEA <br /> LTH unsdlction outside of:San Joaquin Co. <br /> To be corn leted as County. The above food facility meets the <br /> 3. QYt i`j a code. The above checked services are available at the <br /> e commissary is located in perm <br /> changes. <br /> commissary requirements in California if thetstatusaof their operating P t t 202, <br /> above commissary. Please notify <br /> Date_ .._---- <br /> REHS Signature <br /> lA <br /> 8 E.Hazelton^ve <br /> nue <br /> X86 <br /> I Stockton,California 95205 I T 209 468-3420 I F 209 464-0138 I vrnw.sjgov.orgleh <br />