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Environmental Health Department <br />> <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#75823M3 <br />Bus. Ph.(831)869-8611 <br />Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Date <br />g <br />Date <br /> Electrical hook-ups <br />0 Toilet and handwashing <br />0 Potable water <br />EJ Vehicle w <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />co <br />5 <br />_____________________FA#_______ <br />________Bus. Phone 209-338-3663 <br />Owner/QperatorWilliam Berkowitz <br />Business Name^oro Manchado_________ <br />Owner/Operator NameNoellia Cazares <br />Business Mailing Address 204 Halloran Ct <br />Cjtv Brentwood StateCA Zip94513 Bus. Ph. 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' Date 6 <br />51 <br />51 <br />8? <br />—-2 <br />3i <br />B 3-compartment sink <br /> Food preparation <br />O Store refrigerated food <br />Overnight parking <br />, hereby state that the information I have provided <br />S’ <br />P° « <br />■ SAN JOAQUIN <br />-COUNTY- <br />G r t? o i n (■. s s \v <: ! < >, <br />u> <br />0) <br />SwS <br />Us <br />GJ o°’ <br />Commissary Name Max's Kitchen LLC <br />Address1211 8. 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 requirement <br />operator fails to comply with the conditions of this agreement, or if this agreement is modifier <br />commissary ownep^hall notify the EHD immediately. <br />Siqnature^^j^^^' ............................ <br />E o o <br />c <br />S3 <br />O o c <br />i <br />cl <br />,4. <br />(\J>. To be completed by the ENV HEALTH jurisdiction outside of San] <br />The commissary is located in G) V A so Wb l_C\ County. The above food <br />commissary requirements in California Health & Safety Code. The above checked services a <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 |J