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Environmental Health Department <br />Lie. Plate #6M27211 <br />Bus. pfr (209) 362-8415 <br />Date <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Date <br />0 Electrical hook-ups <br />0 Toilet and handwashing <br />El Potable water <br />0 Vehicle wash <br />?? Greatness <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />_FA#______ <br />________Bus. Phone 209-338-3663 <br />Owner/Operator William Berkowitz <br />SAN JOAQUIN <br />------COUNTY------ <br />grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />| 1. To be completed by APPLICANT <br />■ /TTT. <br />___Date 06/ <br />| 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. | <br />The commissary is located in •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 <br />Business Name Los Reyes Mar Y Tierra Inc <br />Owner/Operator Name Giselle Ceja <br />Business Mailing Address 2346 Holly Drive <br />City Tracy StateCA Zip 95376 Bus. Ph.lzu^ ooz-o4 io A|t Ph <br />I.------------------------------------------------------------ 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 />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 Max's Kitchen LLC <br />Address 1211 S. 7th Street <br />City Modesto zip 95351 <br />Check all appropriate services provided: <br />K? 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />0 Overnight parking <br /> . hereby state that the information I have provided is current, true and <br />Wastewater disposal <br />Solid waste disposal <br />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