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SANAUQuIN Environmental Health Department <br /> 4 �Tv <br /> COMMISSARY AGREEMENT <br /> Mobile Fait Faahly• Catera <br /> 001`0 a*11NN14 r WW 2. K mor comr—:= - 'to:5 cwttor r.(San !. <br /> r — <br /> 1. Ta be �tedJjAPIPUCANT <br /> Business Name Chase The,%;, '.i t F'Inte ro <br /> owneociperator Name Eugenia D esha tiuustt Business Mildinq/address 3243 Hal! Dr — <br /> CrtyTr*Cy State_CA Zrp 9QL6 Bus.Ph.(510)8305323—Aft. Ph. <br /> I t*reby state tnat the abm-e rnfOmlat*n is current true snit corned to <br /> thb boat of my knowledge and aorno bo Utilizw m'i aic-provod commissary in size:1areC viith California Health 8 <br /> Safety Cage snit San dcaquin County Environmental HeaAh fkpanment kEHD)req-iremeras if the usa of the <br /> commissary t4 discontinued.the permit folder m::st rtatiry the EHD_ Feitu•F to nolliv 1h+s atflce may result In permit <br /> revocaWn and w.*bes <br /> SI-Inatura Ds� <br /> L2—To b+a�atpleied bb C0 1SSARY IO <br /> OWNERPE�T� A` <br /> Commissary Name Max's Kitchen LLC FAX <br /> — <br /> Address 1211 S. 7th Street Bus Phone 209-338-3$63 <br /> City Modesto Zip95351 0vvtwr;4peratorWilliarnBerkowitz <br /> Check all appropriate services prowdod; <br /> 0 Wastewater drsposal 93 3-oompartment sink 0 Electrical hook-ups <br /> B Solid waste disposal D Food preparation is Todet and handwasIning <br /> 0 Hot 8 Coldwater for Meaning ❑ store refrigerated food 0 Potable water <br /> O Store dry food/suppltes 11 Overnight parking 0 Vehicle wash <br /> l Mark Luis Cruz .hereby state that the tnformalion I have provided is Cu,rent true and <br /> caned to the beat of my knorrt64ge,Ord mitts rhe c*ipr-.r Heats a Satan Corte requirements It the food facility <br /> operator falls to comply with the condliov 9 cf this agreement. or If this agreement is modified or cancelled the <br /> catnrMSAry vine• notify m EHD immedurtety <br /> Signature Date DS-Iq-ty <br /> E-3 -To be compWW by the ENV HEALTH jurisdiction outside of Sa <br /> Tt►e commissary is located in aan:'=Masi County. The above food facility meets the <br /> commissary requirements In Callfomle Health 6 Safety Code The above checked servxes are avatlabk at the <br /> above commissary- Please notify EHD 11 the status of their operstung permit changes. <br /> vi <br /> RENS Signature Date 0/121 <br /> 12o2q <br /> 1888E Hazelton Avenue I Stockton rablomda 652051 T 209 468-3420 1 F 20048"133 I www.tlgaw txgrena <br />