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Mork Liwicki, R.E.H.S. <br />Mmistrod frmeremal 14mM 8commo <br />Errolronments1Resources <br />Comexmo Wry. <br /> <br />$uno C <br />Mafia% CA M4M-IMM <br />MM) 5M4700 <br />id PM $754731 <br />CM MOM 27,438. <br />rowit elsoMelegmes opm <br />srmisetancoutetcom <br />WE BUILD COMMUNITY <br /> <br />Environmental Health Department <br />;SARY AGREEMENT <br />Food Facility • Caterer <br />Cowie?. Mclean I and 2. If your commissary Is located outside of San Joidelin County oleo complete section 3 <br />ca..191Le r <br />Business Name Gina's Tacos Lie. Plate #4VP 1952 <br /> <br />opmeropetater Name Guillermina Velazquez <br />Business Mailing Address 404 S Central Ave <br />City LOdi State C zip 95240 Bus. Ph. (209)735-0784 Alt, Ph. A <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 END. Failure to notify this office may result in panne <br />tevocabon and penalties. <br />Signature <br />FAit <br />Address 1211 S. 7th Street Bus. Phone 209-338-3663 <br /> <br />Date <br />[2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br />City Modesto Zip 95351 <br />Check all appropriate services provided <br />Wastewater disposal E51 3-compartment sink <br />to Solid waste disposal CI Food preparation <br />ri Hot & Cold water for cleaning CI Store refrigerated food <br />Electncal hook-ups <br />ia Toilet and hanciwashing <br />El Potable water <br />Owner/Operator William Berkowitz <br />Store dry feed/supplies 111. Overnight parking Vehicle wash <br />Mark Luis Cruz . hereby state that the information I have provided is current true and correct tothe best of my Yoeviledger, and meets the California Health & Safety Code requirements. lithe food tacility <br />operator fails to Comely with the conditions of this agreement or if this agreement is modified or cancelled, the <br />corretilwry ownershalln the END immediately,. <br />Signature Date 01/2V25- <br />18455 E Ha IooAeniJe1 Stoakton, Calitorive 95205 1 T 209 468-3420 1 F 209464-0138 worn sjgov orgfehd <br />inpleted IN the ENV HEALTH Jurisdiction outside of San Joaquin Co I .... , . , <br />The cantmissary I located in County. The above food facility meets the <br />commissary requirements in Califernia Health & Safety Code. The above checked services are available at the above commissary, please notify EH if the Minus of their operating permit changes. <br />A REHS Signature • Date 3- 2023-