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Environmental Health Department <br />J <br />Lie. Plate#4X04919 <br />Bus. Ph. (209) 996-5839 <br />Date 3 — I - <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />D ate<2 3// <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 <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 />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in nIU 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 />REHS Signature Date rr? u-\ C\. <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner sMlmot+fy-the EHD immediately. <br />Signature <br />53 Electrical hook-ups <br />E2 Toilet and handwashing <br />El Potable water <br />0 Vehicle wash <br />Business Name Las Monarcas Mix <br />Owner/Operator Name Brenda Ochoa <br />Business Mailing Address 1314 N Denair Ave <br />City Turlock StateQA Zip 95351 Bus. Ph. yuo-oody A)t ph <br />i 1 (l \ ------ <br />X------kA /\/^ P* ~, hereby state that the above information is current, true and correct to <br />thejoest 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 anclpenalties. . <br />S i g n atu re A a______y A. y i C <br />_____________________FA#_______ <br />________Bus. Phone 209-338-3663 <br />Owner/Operator William Berkowitz <br />•_______i\oi- pre. .<•' <br />•U'v-S. \z-d-VlcLi. ' <br />S 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />S' 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 the California Health & Safety Code requirements. If the food facility <br />Commissary Name^ax s Kitchen LLC <br />Address 1211 S. 7th Street________ <br />City Modesto zip 95351 <br />Check all appropriate services provided.-'^^^^J’^’T, <br />Wastewater disposal <br />I2i Solid waste disposal <br />0 Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I Mark Luis Cruz <br />SAN JOAQUIN <br />------COUNTY------ <br />3 r V D ! fi c S S ’J rc : ;I t '• =