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IVlia-O �a 01011�� a� �1 ?ilk C� ��, �a i�uiff� <br />COMMISSARY AGREEMENT <br />C®r�a�lefe seetr®ns 1 and if your cornn�ls�ary� is Ionated ®utslde ®f San Joaquin Counfy also complete section 3 <br />'i TA <br />be <br />A <br />. <br />PPLICANT <br />Business game Taste of Texas Barbecue Lic. Plate #4WH3725 <br />Owner/Operator Flame Phillip Dorian <br />Business Mailing Address PO Box 82 <br />Cly Byron State CA Zip 94514Bus. Ph. (925) 444-5974 Alt. Ph. <br />' ,hereby state that the above information is current, true and correct to <br />the lyest 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 />Date <br />Commissary Mame Max`s Kitchen LLC FA# <br />Address 1211 S. 7th Street Bus. Phone 209-338-3663 <br />City Modestoodesto Zip 95351 Owner/OperatorV\rilliam Berkowitz <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />IliaHot & Cold water for cleaning <br />® Food preparation <br />® Store refrigerated food <br />® 3 -compartment sink <br />� <br />Toilet and handwashing <br />Potable water <br />Electrical hook-ups <br />® Stare dry food/supplies <br />6� Overr►ight parking � � �R � Vehicle wash <br />I, Mark Luis Cruz , hereby state that the information I have provided is current, true and <br />:orrect 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 />At <br />Sig <br />The commissary is located in J�`���� ----- <br />County. The above food facility meets the <br />commissary requirements in California Health &Safety Code. The above checked services <br />above commissary. Please notify EHDtheare available at the <br />tus of their operating permit changes.Date <br />REHS Signature <br />1868 E. Hazelton Av�nue � Stockton, California 95205 � T 209 468-3420 � F 209 464--0138 1 www.sjgov.org/ehd <br />