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Environmental Health Department <br />Complete sections 1 and 2. <br />Date <br />REHS Signature.Date <br />EZ Electrical hook-ups <br />0 Toilet and handwashing <br />El Potable water <br />0 Vehicle wash <br />______________________FA# <br />_________Bus. Phone 209-338-3663 <br />Qwner/Operator William Berkowitz <br />1/ <br />If your commissary is located outside of San Joaquin County also complete section 3. <br />| 1. To be completed by APPLICANT " <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 />_______________Date ~Z/_________ <br />/ / <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />------COUNTY----- <br />Greotness grows here. <br />_Lic. Plate# QTY7 J __Business Name Tacos El Coyote Y Su Topa Loca <br />Owner/Operator Name Gabriel Alviter <br />Business Mailing Address ^8 Collinav #2 <br />City Tracy <br />I. < 11A M 0 <br />the best of my knowledge and agre& <br />Safety Code, and San Joaquin Coljnl <br />commissary is discontinued/ the permi <br />revocation and penalties. , ;.j( <br />Signature____________' ‘11! <br />Date <br />K? 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />____, 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 />S ig n atu re <br />Commissary Name Max's Kitchen LLC <br />Address 1211 S. 7th Street <br />City Modesto zip 95351 <br />Check all appropriate services provided: <br />S2 Wastewater disposal <br />Solid waste disposal <br />0 Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I Mark Luis Cruz <br />State CA Zip 95376 Bus Ph (209) 740-5909 A|t Ph <br />■ hereby state that the above information is current, true and correct to <br />to utilize my approved commissary in accordance with California Health & <br />^Environmental Health Department (EHD) requirements. If the use of the <br />trolder must notify the EHD. Failure to notify this office may result in permit <br />Date_ 05/011 ^-5 <br />2. To be completed by COMMISSARY OWNER/OPERATOR ~