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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#4DS4549 <br />Bus. Ph.(209) 345-0853 Alt. Ph. <br />Date <br />2. To be completed by COMMISSARY QWNER/OPERATOR <br />Date REHS Signature. <br /> Wastewater disposal <br />0 Solid waste disposal <br />0 Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I Mark Luis Cruz <br />0 Electrical hook-ups <br />0 Toilet and handwashing <br />Ef Potable water <br />El Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Pt? ^0023^ <br />_____________________FA# <br />_________Bus. Phone 209-338-3663 <br />Owner/Operator William Berkowitz <br />Business Name The Blue Collar Cafe <br />Owner/Operator Name Richard Wesley <br />Business Mailing Address 5313 Darpinian Ct <br />Cjty Riverbank StateCA Zip95367 <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 />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 0^/05/202^ <br />SAN JOAQUIN <br />COUNTY- <br />Greatness grows here. <br />Commissary NameMax s Kitchen LLC <br />Address 1211 S. 7th Street <br />City Modesto zip 95351 <br />Check all appropriate services provided: <br />EZ 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Et 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 own^-j; sh^lljiotify the EHD immediately. <br />Signature.