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' - <br />Environmental Health Department <br />■ - <br />* <br />Lie. Plato t617&4A1 <br />Bu5 Ph (209)452-7108 <br />'• <br />Date. <br />1 <br />-■ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-34201 <br />- <br />/ <br />.t ■. <br />SANMAOUIN <br />COUNT*------ <br />Grcolf'**' <br />?. t <br />■. j <br />I <br />’ I <br />I <br />; -■ ■ <br />' ’! ■ '’^7. <br />t ■' <br />b-• ’ • <br />I- ' <br />t - <br />n " * <br />F 209 464-0138 | www sjgov.org/ehd <br />, ____ <br />____________________________FA#_______________________ <br />Bus Phone 209-338-3663 <br />Owner/OperatorWiHiarn Berkowitz_____________ _ <br />'bf StW 0r» Hu VO'JcO jxnuj o'r r+vs . <br />E3 Electrical hook-ups <br />E Toilet and handwashing <br />0 Potable water <br />0 Vehicle wash <br />■ <br />S 1 • ■ ■ , <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />sections 1 2. Myour oomnissary Is healed oufsido of Son Joaquin County also comploto section 3. <br /> <br />1 1 To be completed by APPLICANT ________ ___ _ _ . <br />Business Name Traveling Tom‘9 Coffee Of Lodi <br />Ownef/Operator Name Joe Spencer <br />Business Mailing Address PO Box 1371 <br />City ^Pon State CA ap 95366 Bus. Ph.(2Qg> <52-7108 Ait. Ph. <br />I. _____________ . hereby state that the above infcxmabon is current true and correct to <br />the best of my knowledge and agree to utilize my approved commssary in accordance wWi California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. H the use of the <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result In permrt <br />revocation and^pnahres z-> / <br />Signature ------------------------------------------------------Date ^2x5^ <br />.' _..X—---- - _______ ____-___’ ____-___-__________ <br />12. To be completed by COMMISSARY OWNER/OPERATQR________________ <br />Commissary NameMax's Kitchen LLC <br />Address 1211 S. 7th Street <br />City Modesto ztp 95351 <br />Chee* ail appropriate services provided: <br />0 Wastewater disposal <br /> Solid waste disposal <br />El Hot & Cold water for cleaning <br /> Store dry food/suppltes <br />I Mark Luis Cruz <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements If the food fadlRy <br />operator fads to comply with the conditions of this agreement, or if this agreement Is modified or cancelled the <br />commissary owner syi not *y the EHO immediately. <br />S^natuze-----__________________________________Date Of j7 ^27________ __ <br /> <br />fTTo^be^ completed jyjhe_ENV HEALTH jurisdiction outside of San Joaquin Co j <br />The commissary b located In Counh, Th« __ . <br />rammrssav requirements In Calfcma HealthfsaWCode. The above checked servfceX^aXbte at he <br />above commissary lease notify EHD If the status of their operating permit changes. <br />REHS Signature Date 8'l?sl^S <br />' r ' ' • <br />- ** • — •, <br />■ ' /• <br />& <br />Q 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />0 Overnight parking <br />------, hereby state that the information I have provided is current true and <br />operator fads to comply with the conditions of this agreement, or if this agreement Is modified ---------- _ . r no(jfy EH0 <br />I ■. I <br />SV- 1