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SANwJOAQUIN Environmental Health Department <br /> C 0 a �I r Y-- Q <br /> Greatness chows her,-. '<: <br /> COMMISSARY AGREEMENT a ,,�5 <br /> Mobile Food Facility ® Caterer <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 /> Business Name Tacos El Gallo #a Lic. Plate#84163G3 <br /> Owner/Operator Name Antonio Paez <br /> Business Mailing Address 310 Bodem St <br /> City Modesto State CA Zip 95350 Bus. Ph. (209) 408-3201 Alt. 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 appFoved 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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Max's Kitchen LLC FA# <br /> Address 1211 S. 7th Street Bus. Phone 209-338-3663 <br /> City Modesto Zip 95351 Owner/Operator William Berkowitz <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal E3 3-compartment sink 0 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 Ed Potable water <br /> ® Store dry food/supplies 9 Overnight parking 121 Vehicle wash <br /> 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 pate /TI/Z "l <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in �li ,� 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 notify EHD if the atus of their operating permit changes. p <br /> REHS Signature Date t 2- <br /> Ilv'� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> ?R 25 NZ(0 l <br />