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SAN -JOAQUIN Environmental Health Department <br /> ----COUNTY <br /> Greatness arows her, <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 C. he� )-A,h 11ip firs Lic. Plate# 77 7 Y'3 <br /> Owner/Operator Name Esc:;u R140C._4> <br /> Business Mailing Address �Z °A6 � �'- <br /> City l� jAb`1-58tate( , Zip '153cli Bus. Ph. `51 ''_)(- � 70 � Alt. Ph. <br /> I, &1 Q-+P y V7L-�L"' 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 /> 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 Zip 95351 Owner/Operator William Berkowitz <br /> Check all appropriate services provided- <br /> 0 Wastewater disposal 12 3-compartment sink 0 Electrical hook-ups <br /> 0 Solid waste disposal ❑ Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning ❑ Store refrigerated food 9 Potable water <br /> * Store dry food/supplies 0 Overnight parking LJ 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 shall notify the EHD immediately. <br /> Signature Date z�2, LRzw'-'` <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in C-)TA' ` kl`�11 0" ; - 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 /I ZI 21�21A <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 w�ww..ssj-go"v..org/ehd <br /> fv <br /> P1�� J lcnu�� <br />