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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 />Gee 115^7Lie. Plate# <br />Bus. Ph, (209) 740-5909 Alt. Ph. <br />Date <br />2. To be completed by COMMISSARY OWNER/QPERATOR <br />Date <br />DateREHS Signature. <br />E2 Electrical hook-ups <br />EZI Toilet and handwashing <br />Ei 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 />SAN JOAQUIN <br />------COUNTY- <br />Greatness grows here. <br />_____________________FA# <br />_________Bus. Phone 209-338-3663 <br />Owner/OoeratorWilliam Berkowitz <br />EJ 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 />Business Name Tacos El Coyote Y Su Topa Loca <br />Owner/Operator Name Gabriel Alviter <br />Business Mailing Address Collinav #2 <br />CityTracy StateCA Zip95376 <br />I, Co Ar6I Au _, 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 />in Cdunty Environmental Health Department (EHD) requirements. If the use of the <br />hp perrqit holder must notify the EHD. Failure to notify this office may result in permit <br /> (o/o ' <br />Safety Code, and San Joa^ <br />commissary is discontinued <br />revocation and penakiesf <br />S ig natu re( \ <br /> 7/?^ AT <br />~7 ' <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 />10/1 <br />Commissary Name ^ax s Kitchen LLC <br />Address *1211 S. 7th Street <br />City Modesto zip 95351 <br />Check all appropriate services provided: <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 />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 />Sig nature_____<