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SAN JOAQUIN co UNTY <br />KO 5,141V1O Environmental Health Department <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 />To be completed by APPLICANT <br />Business Name Tacos La Cochinita Lic. Plate #4TZ8148 <br />Owner/Operator Name Octavio Castaneda Salinas <br />Business Mailing Address 510 Czerny St <br />City Tracy State CA Zip 95736 Bus. Ph. (209) 771-6399 Alt. Ph. <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 />Address1211 S. 7th Street <br />Bus. Phone 209-338-3663 <br />FA# <br />City Modesto <br /> <br />Zip 95351 <br /> <br />Owner/Operator William Berkowitz <br /> <br />Check all appropriate services provided: <br />o Wastewater disposal <br />13 Solid waste disposal <br />0 Hot & Cold water for cleaning <br />Store dry food/supplies <br />I, Mark Luis Cruz <br />El 3-compartment sink <br />O Food preparation <br />Store refrigerated food <br />Overnight parking <br />Et Electrical hook-ups <br />0 Toilet and handwashing <br />15 Potable water <br />0 Vehicle wash <br />, 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 own-; sh.411 notify the EHD immediately. <br /> <br />Date -0-1-2 4/ Signature <br /> <br />3. 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. Please notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd