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SAN MAP N <br />PO S% <br />Environmental Health Department <br />COUNTY <br />Greatness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />RECEIVED <br />APR 08 7.02 4 <br />SIANISA ESOURCES IS <br />DEPT OF EINIROWENIAL R <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 />Owner/Operator Name Octavio Castaneda Salinas <br />Business Mailing Address 510 Czerny St <br />City Tracy State CA Zip 95736 <br /> <br />Bus. Ph. (209) 771-6399 Alt. Ph. <br /> <br /> , 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 />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br />Address 1211 S. 7th Street Bus. Phone 209-338-3663 <br /> <br />City Modesto <br /> <br />zip 95351 <br /> <br />Owner/Operator William Berkowitz <br /> <br />Check all appropriate services provided: <br />Wastewater disposal GI 3-compartment sink F2 Electrical hook-ups <br />Solid waste disposal --11Y-Food preparation- 10 °-‘ \c„.‘0\-1 Ea Toilet and handwashing <br />Pi Hot & Cold water for cleaning —1V—Store refrigerated-food- 15 Potable water <br />po-c ---E3 --Store-dfy-foodisupplies- udi Overnight parking El Vehicle wash <br />I, 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 oe/A <br /> <br />Date 0Y -055 -29 <br /> <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin 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. Please4 IifyEHD if the status of their operating permit changes. <br />REHS Signature AWAdrOl ES'i-ra.Gt 61 Date DL-{10 t202(--1 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Lic. Plate # 4TZ8148 <br />FA# <br />Business Name Tacos La Cochinita