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2- P � a3 � <br /> y e AOAQUIN Environmental Health Department <br /> _-.c oUNTY--._ p <br /> . a C'e'lln-Ss grows liver <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility• Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3- <br /> 1. To be Com leted b 'll P iCANf,, <br /> Business Name Tortilleria Mexico Mi Amor Lie.Plate# M5994 <br /> OwnerlOperator Name Karen Femanda Equivel Lopez <br /> Business Mailing Address 3712 Popolo Cir <br /> City Stockton State CA Zip 95212 Bus. Ph.(209)426-8020 All.Ph. <br /> t. ,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. Fallure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date <br /> 2. To.tyecom letet� b COMM155ARY OWNE> <br /> Commissary Name Max's Kitchen LLC FA# <br /> Address 1211 S. 7th Street Bus. Phone 209-338-3663 <br /> City Modesto 7ip95351 OwnerlOperatorWlliamBerkowi1Z <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal ® 3-compartment sink la Electrical hook-ups <br /> 0 Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> 0 Hot&Cold water for cleaning 0 Store refrigerated food 121 Potable water <br /> 13 Store dry food/supplies 6r Overnight parking <br /> 1121 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 /> Date <br /> Signature <br /> The commissary Is located in _ S t"� r<U-'u� _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 0Dmmi5sary. Please notify EHD if the status of their operating permlt changes. I <br /> REHS Signature_�� Date 0 <br /> 1868 E.Hazelton Avenue I Stockton, California 952051 T 209 466-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />