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Environmental Health Department <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 />Lie. Plate #4367120 <br />Bus. Ph. 1650) 977-8902 <br />Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />REHS Signature — Date — * <br />1868 E Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br /> <br /> <br />0 <br /> Electrical hook-ups <br /> Toilet and handwashing <br />El Potable water <br />El Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />______________________FA#________ <br />_________Bus. phone 209-338-3663 <br />Owner/Operator William Berkowitz <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in --------------------------------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 />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />I Mark Luis Cruz_____________ <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 shallnptif/the EHD immediately. <br />Signature <br />Commissary Name Max s Kitchen LLC <br />Address S. 7th Street <br />City Modesto zip 95351 <br />Check all appropriate services provided: <br />Q 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Ef Overnight parking <br />r hereby state that the information I have provided is current, true and <br />Date <br />Business Name NaP°li Foods LLC <br />Owner/Operator Name Yael Smadja <br />Business Mailing Address -2007 ClaLJS Rd <br />City Modesto StateC^Zip 95355 ------^s. HP. ----------- -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 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 />SAN JOAQUIN <br />A—COU NTY------ <br />'. Greatness grows here.