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Environmental Health Department <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 />Lie. Plate#4WH3725 <br />Bus. Ph, (925) 444-5974 <br />Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Date <br />REHS Signature Date <br />Q Electrical hook-ups <br />El Toilet and handwashing <br />0 Potable water <br />El Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />_____________________FA# <br />________Bus. Phone 209-338-3663 <br />Owner/OperatorWilliam Berkowitz <br />Business Name Taste of Texas Barbecue <br />Owner/Operator Name Phillip Dorian <br />Business Mailing Address PO B°x 82 <br />City Byron StateCA Zip94514 Bus. Ph. 444-DU/4 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 />0 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />, hereby state that the information I have provided is current, true and <br />SAN JOAQUIN <br />- COUNTY— <br />Greotnt-ss grows here. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />S'--------s <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 rectify EHD jtthe status of their operating permit changes. <br />io/\Q 7^2.5 <br />' 7 <br />Commissary NameMax s Kitchen LLC <br />Address 1211 S. 7th Street <br />City Modesto zip 95351 <br />Check all appropriate services provided: <br /> Wastewater disposal <br />0 Solid waste disposal <br />0 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 <br />operator fails to comply with tne conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />Signature