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imp! is700 <br />0,0 4:1)0, 6 71, <br />(Xel <br />Ems.. <br />WWW stancountv corn <br />WE BUILD COMMUNITY <br />.SARY AGREEMENT <br />rood Facility • Caterer <br />Mark Lawicki, R,E.H.S, <br />Re9ritew7 Fnrravne.lv hoer. sev.ere <br />Environmental Resources <br />COMKOC. WM} SU,* C <br />4410e0o CA li!,3 SA 4494 <br />Environmental Health Department <br />complete so, t,,•/,: ,W).7 ) 11 your commissary is located outside of Sall I .Z complete section 3 <br />I 1. To be_con_r.ipleted by_APPLICANT <br />Business Name Gina's Tacos <br />Owner ,Operator Name Guillermina Valazquez <br />Business Mailing Address 404 S Central Ave <br />City LOdi State CA zip 95240 Bus. Ph. (209)735-0784 Alt Ph. <br />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 (END) 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 revocation and penalties <br />Signature <br />Lic Plate # 4 VP 1952 <br />Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br /> <br />FA# <br /> <br />Address 1211 S 7th Street <br />City Modesto zip 95351 <br />Check all appropriate services provided <br /> <br />Bus. Phone 209-338-3663 <br /> <br />Owner/Operator William Berkowitz <br /> <br />Wastewater disposal Ed 3-compartment sink 621 Electrical hook-ups <br />Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br />Hot & Cold water for cleaning El Store refrigerated food El Potable water <br />commissary owner shall ti the EHD immediately. <br />operator fails to comply with the conditions of this agreement or if this agreement is modified or cw..:elled, tie <br />Store dry food/supplies Er Overnight parking 12:1 Vehicle wash <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements If the food facility <br />I, Mark Luis Cruz . hereby state that the information I have provided is current true and <br />Signature Date 07/21/2 5- <br />15.---ro be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co) <br />''-V A -' County The above food facility meets the The commissary is located in _ --_-_Th C _S r (r 0.,( <br />commissary requirements in CalifOrn a Health & Safety Code The above checked services are avadable at the <br />above commissary Please notify EH If the status of their operating permit changes <br />).' <br />RENS Signature <br />Date 3- <br />7 __.' <br />1808 E. Nazetton Avenuei Stockton calitorma 952051 T 209 468-3420 1 F 709 4641-013tr j Aww sigov.orglehd