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eted <br />JUc Plate# <br /> Date <br />Date <br />DateREHS Signature <br />1868 E Hazelton Avenue | <br />S3 Electrical hook-ups <br />B Tone! and hand washing <br />0 Potable water <br />0 Vehicle wash <br />revocation <br />Signature <br />---------------------------------- <br />-------------Bus Phone 209-338-3663 <br />.Owner/Qperator William Betkowitz <br />£3 Wastewater disposal <br />0 Solid waste disposal <br />0 Hot & Cold water for cleaning <br /> Store dry food/supphes <br />I Mark Luis Cruz <br />C0MMr <br />LlCANf <br />LPararti— <br />Environm <br />sa^OAOUIN <br />ft * ' ' r'l I',' . <br />2 To be coi leted_by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br />Address ^211 S. 7th Street <br />City Modesto Z)p 95351 <br />Check all appropriate services provided <br />Q 3-compartment sink <br />O Food preparation <br /> Store refrigerated food <br /> 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 (he California Health & Safety Code requirements I! 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 EHO immediately <br />Signature <br />'Mingale Ct ~ -------------- -------- <br />lp-S535fiZZBus Ph (2091 495-3609 A>1 r,r —— <br />_ -• and pena#ws Pa™ hoMe, mus, ,ha EH0 r <br />°n,a,H^oOpanrne,it <br />S be corn <br />BuS'neSsNaniB ( <br />' —-AudTAR^ ~S,a|e_CAZ1| <br />"you, <br />‘“'■AR^fJtGREEMENT <br />acill,v • caterer <br />J——- x *° ccnWK wction 3 <br />- - - . _ ------ <br />-------- <br />[sTfo be completed by the ENV HEALTH jurisdiction outside of San Joaquin CoJ <br />The commissary is located in _____________CounV* The above ,aci’,'Y ™e'5 lhe <br />commissary requirements in Califomia'Health & Safety Code The above checked services are available at the <br />above commissajy Please notify EHD if the status of their operating permit changes <br /> Date 'Is ii&'l _____ <br />Stockton California 95205 j T 209 468-34201 F 209 464-0138 | wwn sjgov.orglehd