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�7 � kJ h�� 8 K U � &J <br /> � � Cft <br /> �c ' ��U �� <br /> � � � *M D� � A � Environmental x n� <br /> ~,�� . ,~° ="��� = , ^ , �� �nun <br /> ---- rt <br /> C[JL] T-,lTY�-- <br /> G'ennveo grows he/v. - <br /> x�������U������ �� � ��U���K�0�U�U�^� <br /> COMMISSARY AGREEMENT <br /> Mobile Food F8Ci|ih/ * Caterer '^ <br /> Complete sections / and 2. If your commissary is /000&*d outside of San Joaquin County also uon7pAeA*maobnn 3. <br /> 1. To be completed by APPLICANT <br /> Business Name Tacos E| Gallo 4*a Lio. plate 84163G3 <br /> Owner/Operator Name Antonio Pmez <br /> Business Mailing Address 310Bodem8t <br /> City Modesto StateCA Zip95350 Bus. Ph. (208) 408 32U1 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 (EHO) 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 /> � <br /> Signature Date <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Max's Kitchen LLC <br /> Commissary Narn <br /> Address 1211 S. 7th Street Bus, Phone 209-338-3663 <br /> City Modesto Zip 95351 Ovvnar/Openato Willi@Ol B8[kDVVitZ <br /> Check all appropriate services provided: <br /> [3 Wastewater disposal Q 3-compartment sink E3 Electrical hook-ups <br /> ..^_ <br /> 13 Solid waste disposal E3 Fond preparation 0 Toilet and hmndxxmshing <br /> 0 Mot & Cold water for cleaning [3 Store refrigerated food mf Potable water <br /> E3 Store dryfood/aupp|ims Overnight parking IM Vehicle wash <br /> |. N1a[h Luis Cruz . hereby state that the information | have provided is current, true and <br /> correct tothe best ofmy knuw|edge, 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 oanoe||ed, the <br /> commissary owner shall notify the EHOimmediately. <br /> Signature Om <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Healthh Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the�ratus of their operating permit changes. <br /> REHS Signature Date <br /> To be completed by the ENV,H8ALT- H jurisdiction outside of San Joaquin <br /> C�`~7 / �'� <br /> \ ��^- ���� �-�/ V �~ <br />