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SAN_JOAQUIN Environmental Health Department <br />P <br />—COUNTY <br />C.-ewress <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 />Business Name Burgers R 4Ever Lic. Plate #4W51°1 <br />Owner/Operator Name Travis Cobarrubia <br />Business Mailing Address 4150 Rocky Point Ct <br />c ity Tracy State CA zip 95304 Bus. Ph. (510) 507-9497 Alt. Ph. <br />I \ 3C,0\oca 6k. , 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 /> <br />Date it ( Vit <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br /> <br />FA# <br />Address 1211 S. 7th Street <br />City Modesto zip 95351 <br />Check all appropriate services provided: <br /> <br />Owner/Operator William Berkowitz <br /> <br />0 Wastewater disposal <br />d Solid waste disposal <br />a Hot & Cold water for cleaning <br />El Store dry food/supplies <br />El 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />ral Overnight parking <br />Electrical hook-ups <br />Q' Toilet and handwashing <br />csif Potable water <br />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 13 /2M <br />3. To be completed by the ENV HEALTH jurisdiction outside ofSan Joaquin <br />The commissary is !cleated in 5-1-1244,„; slatt..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 E I if the of their operating permit changes. <br />REHS Signature Date 11113/2-0Z(-4 <br /> <br />1868 E. Hazelton A ue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />PiQ09-{gglq <br />Bus. Phone (209) 338-3663