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S A N 1 O A Q U I N Environmental Health Department <br /> ) R � y� 2 ,61 <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 Las Ta atias Lic. Plate#4GN9940 <br /> Owner/Operator Name Elizabeth Mendez Hernandez <br /> Business Mailing Address 5550 East Jahant Rd <br /> City Gait State CA Zip 95632 Bus. Ph.(209 689-4660 Alt. Ph. <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 appl`oved 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 vl ;lu ti�nc.v,c �'L Date � " <br /> 2 To be completedby 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 ® 3-compartment sink 0 Electrical hook-ups <br /> 0 Solid waste disposal E3 Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning © Store refrigerated food El Potable water <br /> 0 Store dry food/supplies el Overnight parking Bl 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 ow s all notify the EHD immediately. <br /> Signature_ Date 6 5-3e-24f <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa On Co.] <br /> The commissary is located in %2A t S 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_ k�; 2-'( <br /> �. <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br />