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Environmental Health Department'W <br />5^’ <br />Lie. Plate#53104P1 <br />Date <br />\/ ^o /z-kREHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | <br />Q Electrical hook-ups <br />0 Toilet and handwashing <br />El Potable water <br />0 Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />-COUNTY- <br />Grectness grows here. <br />_____________________FA#_______ <br />_________Bus. Phone 209-338-3663 <br />Qwner/OperatorWilliam Berkowitz <br />'l 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />B 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />CfVernight 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 ownpr shall notify the EHD immediately. <br />Signature <br /> <br />|~3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co, | <br />The commissary is located in fx)UYvV-|Countv. 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 />Business Name ^-as Ranitas <br />Owner/Operator Name Maria De Rosario Aguilar <br />Business Mailing Address 26909 Dodds Rd <br />City Escalon State CA Zip 95320 Bus Ph (209) 719-0717 A,t Ph <br />■------------------------------------------------------------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 />Date O(-2Q~!2C <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name^ax s Kitchen LLC <br />Address J 211 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 />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />| 1. To be completed by APPLICANT