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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 />Lie. Plate #54888J2 <br />Alt. Ph. <br />Date <br />2. To be completed by COMMISSARY OWNER/QPERATQR <br />Date <br />Date REHS Signature <br />0 Electrical hook-ups <br />0 Toilet and handwashing <br />Ef Potable water <br />0 Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />____________________FA# <br />________Bus. Phone 209-338-3663 <br />Owner/Operator William Berkowitz <br />SAN JOAQUIN <br />------COUNTY------ <br />Greatness grows here. <br />1. To be completed by APPLICANT <br />The commissary is located in <br />commissary requin <br />above commissary <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 />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> County. The above food facility meets the <br />eynents in California Health & Safety Code. The above checked services are available at the <br />. Plbase notify EHD if the status of their operating permit changes. <br />MowqIsIa ___Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />^2^0022^ <br />Commissary NameMax s Kitchen LLC <br />Addtoss'!211 S. 7th Street__________ <br />City Modesto zip 95351 <br />Check all appropriate services provided: <br />0 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 />Signature <br />Business Name Valley Brew & Chai Cafe <br />Owner/Operator Name^a'03^ Gedela <br />Business Mailing Address 1538 Rock Spring Ave <br />City Manteca State CA zjp 95337 Bus .Ph .(408) 644-1800 <br />I, C^ipd-Q.zCiEa • 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