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Environmental Health Department <br />Gr <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County als< <br />1. To be completed by APPLICANT <br />Lie. Plate #4WB9922 <br />Date *'/'0 - 2-^~ <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 />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />' SAN JOAQUIN <br />------COUNTY <br />_____________________FA# <br />________Bus. Phone 209-338-3663 <br />.0wner/Operator William Berkowitz <br />E3 Electrical hook-ups <br />0 Toilet and handwashing <br />Gf Potable water <br />0 Vehicle wash <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 />Signature <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 E2I . <br />Solid waste disposal <br />0 Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I Mark Luis Cruz <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />is .diUxS CqUhK/ _County. The above food facility meets the <br />Business Name Mi Cachito De Mexico <br />Owner/Operator Name^aiJl Jimenez Rubi <br />Business Mailing Address 3724 Prince Andrew Dr <br />Cjtv Riverbank StateCA Zip 95367 Bus Ph (209) 495-5100 A|t Ph <br />I-—Is*0 !—, 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. i <br />Signature^7 Date OZ./jO j <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />MSdmplete section 3. <br />The commissary is located in <-TTT^lCIS \oUHTy C ' TC, <br />commissary requirements in California Health & Safety Code. T^e above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />Kir Date