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fQ� S A N U A Q U I N Environmental Health Department <br /> f_U C <br /> !{, —_ (L fD lJ N T Y--- <br /> 1crF�Pe� Creotness grows here. <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 /> 1. To be completed by APPLICANT <br /> Business Name Papa's Dumplings Lic. Plate#60107X3 <br /> Owner/Operator Name Xiaojiao Zhu _ <br /> Business Mailing Address 1554 Dorothy Cmn <br /> City Livemore State CA Zip 94551 Bus. Ph. (408) 896-5556 Alt. Ph. <br /> I, ' 4� , hereby state that the above information is current, true and correct to <br /> the best of my nowledge and a ee to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin ounty Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,Sh perolder ust notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date <br /> 2. To bedompleted 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 /> Wastewater disposal w! 3-compartment sink M Electrical hook-ups <br /> 0 Solid waste disposal E) Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning 0 Store refrigerated food `r Potable water <br /> 0 Store dry food/supplies 0 Overnight parking ✓ 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 al notify the EHD immediately. / <br /> Signature Date� �/ZSr <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in 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 status of their operating permit changes. <br /> REHS Signature Date <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 /> f�25C)D gD� <br />