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S A N 10 A Q U I N Environmental Health Department <br /> ~—COUNTY--- <br /> COMMISSARY AGREEMENT R D Tas <br /> Mobile Food Facility Caterer F�B,S�USco� RGEs <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County als mplete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name Mi Cachito De Mexico Lic. Plate#4WB9922 <br /> Owner/Operator Name Raul Jimenez Rubi <br /> Business Mailing Address 3724 Prince Andrew Dr <br /> City Riverbank StateState CA Zip 95367 Bus. Ph.(209) 495-5100 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. �Q <br /> Signature ^ L <br /> Date O2/la /2S <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 /> * Wastewater disposal EZ 3-compartment sink ® Electrical hook-ups <br /> ® Solid waste disposal ® Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning M Store refrigerated food El Potable water <br /> 0`Store dry food/supplies 9 Overnight parking 0 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 Date 0z- D- 2.s <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in �o(J aT--/ 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. s <br /> r <br /> REHS Signature , � M C Date 1�2_ i <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 l T 209 468-3420 1 F 209 464-0138 1 www_sjgov.org/ehd <br /> Wq5 w3gq <br />