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Environmental Health Department <br />Complete sections 1 and 2. <br />Lie. Plate#4MH9152 <br />Date <br />Date <br />Ef Electrical hook-ups <br />Toilet and handwashing <br />ST Potable water <br />Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138Jwww.sjgov.org/ehd <br />SAN JOAQUIN <br />------COUNTY------ <br />Grtofness qronr. here. <br />_____________________FA#_______ <br />_________Bus. Phone 209-338-3663 <br />Qwner/Operator William Berkowitz <br />If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name^ax s Kitchen LLC <br />Address 1211 S. 7th Street <br />City Modesto zip 95351 <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I Mark Luis Cruz <br />3-corppartment sink <br /> Food preparation <br /> Store refrigerated food <br />S' Overnight parking <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^r^shall notify the EHD immediately. <br />Signature <br />Business Name The Callejeros Grill <br />Owner/Operator Name Robert Arias <br />Business Mailing Address 2143 West Park <br />City Stockton State CA Zip 95203 Bus. Ph. (2Q9) 621-7909 A|t ph (209) 702-3419 <br />I..---------------------------------------------------------- - 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 <br />Date <br />‘ T <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in Cwwty'_______County. The above food facility meets the <br />commissary requirements in California Health & Safety dope. 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 ^1