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/,.,jJ�_�N c <br /> 1�t S Q N J O Q Q U I N Environmental Health Department <br /> --- COUNTY --- <br /> c',.+Fcn' Greotness grows here. <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 completed by APPLICANT <br /> Business Name ..labor IDP— Mexico_ Lic. Plate <br /> Owner/Operator Name M�.__Flores flue recA _ <br /> Business Mailing Address Zl 2 w [-kovLY l.- <br /> City Ty-ck,!E:� State CIN Zip 53-Tto Bus. Ph.�T_09 ] j2 6-Z.3 'Alt. Ph. <br /> I, V��yy_Cc_ , 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 Oj "10 YO7-S <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Max's Kitchen LLC FA# <br /> Address 1211 S. 7th Street Bus. Phone 209-338-3663 <br /> City Modesto Zip95351 Owner/OperatorVVilliam Berkowitz <br /> Check all appropriate services provided: <br /> * Wastewater disposal W, 3-compartment sink lA Electrical hook-ups <br /> * Solid waste disposal F.1 Food preparation V� Toilet and handwashing <br /> 0— Hot & Cold water for cleaning M Store refrigerated food i?; Potable water <br /> 0 Store dry food/supplies El Overnight parking V Vehicle wash <br /> 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 all notify the EHD immediately. <br /> Signature Date 02 <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 8. 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.oraiehd <br /> T?Q_05 L4 21559 <br />