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SAN JOAQUIN Environmental Health Department <br /> ---COUNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ,, caterer <br /> Complele SeClrons I and 2 If your commrssary is iocared outside of San Joaquin CUunry also complete ,"fiori 3 <br /> F-1 To t e ocx� Ie.J, try APPLICANT --- <br /> _ Lac.Plate# BBB17 3 <br /> Business NamQ <br /> QyYiter/Operator Name <br /> Business Mailing Address 1939 Wall Street (209) 5g7868 Att. Ph. <br /> CityTrac, State CA Zip 95376 Bus. Ph. <br /> SII Ile ,p ���nre2;hereby state that the obove information is current,true and correct to <br /> the best o1 my knowledge and agree to utilize my approved commissary m accordance with Cai'tf mkIf the se 01 ti <br /> Sa" Code. and San J egthe permit t <br /> must notify the EHDHealth �rtment t <br /> Failure notify this offce may result in permit <br /> commissary is disco <br /> revocahon and n Dat© <br /> Signature ✓ <br /> 2. To be completed by <br /> commisY OWNER/OPERATOR <br /> Kitchen LLC <br /> Max's <br /> FA# <br /> Commissary Name 209-338-3663Bus_ Phone <br /> Address 1211 S. 7th Street William <br /> CitBerkowitz <br /> y <br /> Modesto Zip 95351 OwnerlOperator <br /> Check all appropriate services provided: ® Electrical hook-ups <br /> j 1Nastewater disposal Ga 3-compartment sink <br /> Q Food preparation ® Toilet and handwashing <br /> 0 Solid waste disposal (g Potable water <br /> 0 Hot & Cold water for cleaning [3 Store refrigerated food <br /> Iles C?' Overnight parking <br /> ® Vehicle wash <br /> [3 Store dry faodlsupp rovided is current true and <br /> i Mark Luis Cruz , hereby state that the information I have p <br /> correct to the best of my knowledge. and meets(hes a lireemenl orhit th ety sf agreement isCodei modified or�cancellled, the <br /> operator fails to comply with the conditions of th 9 <br /> commissary owner shall notify the EHD immediately. Date03-Z% <br /> Signatur�!��f�� <br /> com leted b the ENV H LTH 'urisdiction outside ofi San Joa u►n COthe <br /> 3 7o be P� The above food facility meets <br /> tial County. <br /> The commissary is located in <br /> missa requirements in California Health & Safety Codeera ng permit changes,Services are available at the <br /> . The above checked <br /> comrY <br /> above commissary. Please notify EHD � he status of thel op � , 2S v <br /> U� v Date <br /> REHS Signature <br /> 20 i F 209 464-0138 <br /> 1868 E. Hazelton Avenue I Stockton, <br /> California 95205 T 209 468-34www.sjgov.orglehd <br /> t _ . <br /> os 3 <br />