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SA N 1 OAQ U I N Environmental Health Dep <br /> artment <br /> �? ---COU NTY <br /> i0r F� Grenoirss grows here. � D <br /> COMMISSARY AGREEMENT FED 0 TVs <br /> Mobile Food Facility • Caterer SE , u ss�RS <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County 91 <br /> q ty als plete section 3. <br /> 1. To be com leted 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 State CA Zip 95367 Bus. Ph.(209) 495-5100 Alt, Ph. <br /> I, u ext 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. f d <br /> Signature t� L <br /> Date. o2/Jo Z7 <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 269-338-3663 <br /> City Modesto Zip 95351 Owner/Operator William Berkowitz <br /> Check all appropriate services provided: <br /> ® Wastewater disposal Q 3-compartment sink 0 Electrical hook-ups <br /> ® Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning II] Store refrigerated food Ed Potable water <br /> ® -Store dry food/supplies 0 Overnight parking 121 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 4Z D- 2.S <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in _ 1. I61)\ ©U r+'� 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 F\ �r I�` l C_ Date <br /> t <br /> 1868 E. Hazelton Avenue Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br />