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SANAAQUI <br />- CO 1-1 N <br />Environmental Health Depa rtment <br />&,k 1° <br />ARY AGREEMENT <br />Mobile Food Facility c'5- Caterer <br />Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />be <br />b APPLICANT <br />Bella Habachi Lic. Plate #___LitLQ2----.3 _ <br />Business Name <br />Owner/Operator <br />Business Mailing Address <br />City State_ Zip <br />-e,7Y)frv? <br />Alt Ph. Bus. Ph. <br />I, 1 <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 (EHD) requirements. If the use of the Failure to notify this office may result in permit <br />2. To be completed-by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br />Address 1211 S 7th Street Bus. Phone 209-338-3663 <br /> <br />City Modesto zip 95351 <br />Check all appropriate services provided: <br /> <br />Owner/Operator William Berkowitz <br /> <br />Wastewater disposal .V 3-compartment sink <br /> 12 Electrical hook-ups <br />0 Solid waste disposal LT: Food preparation <br /> fa Toilet and handwashing <br />0 Hot & Cold water for cleaning ij Store refrigerated food <br /> <br />El Potable water <br />Store dry food/supplies Er Overnight parking <br /> Fa Vehicle wash <br />1, Mark Luis Cruz , hereby state that the information I have provided is current, true and <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 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 />3. To be completed b the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> <br />The commissary is located in 1,%-k ‘c, County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. The above checked services are available at the <br />END if the status of their operating permit changes. <br />RENS Signature <br />Hazelron Avenue Stockton California 95205 I T 209 468-3420 I F 209 464-0138 I www sjgov.org/enci (i6,9)52 5-61 00 <br />commissary is discontinued, the permit holder must notify the EHD. <br />revocation and penalties. <br />Signature Date Of / /6/ <br />FA# <br />Date <br /> <br />Please n above commissary. <br /> <br />Date 0 5 1 3- jqn7 <br /> <br />Ok <br />