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S N JOAQUIN <br />COUNTY --- <br />:trit5s 9.ii•v$, here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <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 />To be completed by APPLICANT <br />Business Name Bama Flavor Lic. Plate #4MB7110 <br />Owner/Operator Name Arthur Allen & Kimberly Absher <br />Business Mailing Address 5513 Cypress Creek Way <br />City Salida State CA zip 95368 Bus. Ph. (209) 750-2542 Alt. Ph. (209) 604-7050 <br />I, ileih 0 v Al 1 e hi i K(mbe-et Al-ik'r i — , hereby state that the above information is current, true and correct to . s <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 enalties. <br />/ / / Ai 1 ' Date 3 (/ <br />i <br />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 />City Modesto zip 95351 <br /> <br />Owner/Operator William Berkowitz <br /> <br />Check all appropriate services provided: <br />Wastewater disposal h2 3-compartment sink 0 Electrical hook-ups <br />Solid waste disposal 0 Food preparation Toilet and handwashing <br />Hot & Cold water for cleaning 0 Store refrigerated food g Potable water <br />Store dry food/supplies 0 Overnight parking g Vehicle wash <br />Signature <br />FA# <br />hereby state that the informatii <br />correct to the best of my knowledge, and meets the California Health & Safety <br />operator fails to comply with the conditions of this agreement, or if this agr <br />commissary owner shall notify the EHD immediately. <br />Signature DatE <br />3. To be completed by the ENV HEALTH jurisdiction o <br />The commissary is located in Counti <br />commissary requirements in California Health & Safety Code. The above <br />above commissary. Please notify EHD if the status of their operating permit <br />REHS Signature Date <br />Mark Luis Cruz <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I I <br />\7g 05L-IU3 I