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Environmental Health Department <br />■j ___ <br />Lie. Plate #9IJLC783 <br />Bus. Ph. 925-487-4679 <br />Date <br />~! <br />Date <br />DateREHS Signature. <br /> Electrical hook-ups <br />0 Toilet and handwashing <br />El Potable water <br />E3 Vehicle wash <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Ef Overnight parking <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />PK.25O0 SIO <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />_____________________FA# <br />_________Bus. Phone 209-338-3663 <br />Owner/Ooerator William Berkowitz <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />I A I I A aw* <br />SI3 <br />Business Name^ansar Indian Cuisine <br />Owner/Operator Name Judge Santokh Singh <br />Business Mailing Address 23262 S Bird Rd <br />City Tracy State CA Zip 95304 Bus. Ph. A|t Ph <br />I. V 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 mij>t notify the EHD. Failure to notify this office may result in permit <br />revocation and penalti^/. / <br />Signature Date <br /> <br />j 2: Tobe completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br />Address1211 S. 7th Street <br />City Modesto zip 95351 <br />Check all appropriate services provided: <br /> Wastewater disposal <br />0 Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <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 ownepshall notify the EHD immediately. —n r <br />Signature Date <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 /> | C> I ^7-0^ <br />SANJOAQUIN <br />------COUNTY------ <br />(jiretrtness g»ows here.