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S A N J dA Q U I N Environmental Health Department <br /> r t r '•i t <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Conoets sections I?nd 2. If your commissary is located outside of San Joagrlln County also complete section 3 <br /> Tfcom leted b APPLICANTS <br /> gosiness Name Pa a's Dum iin s <br /> Lic Plate#60107X3 <br /> owner/Operator Name_ <br /> Xiaojiao Zhu <br /> Business Mailing Address 1554 Dorothy Cmn <br /> City <br /> Livemore State CA Zip 94551 Bus. Ph.(408) 896-5556 Alt. Ph. <br /> l . hereby state that the above information is current, true and correct to <br /> the best of y knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, nd Sa aqu County Env* onmental Health Department (EHD) requirements, If the use of the <br /> commissary is di i ed„ a permit hol r must notify the EHD, Failure to notify this office may result in permit <br /> revocation and pe afties. <br /> Signature <br /> 2. To b om leted 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 OwnerlOperator William Berkowitz <br /> Check all appropriate services provided: <br /> o Wastewater disposal [3 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 ❑ Store refrigerated food IN Potable water <br /> [] Store dry food/supplies 11 Overnight parking 0 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 Date DG 5 *—Zr <br /> 3. To be completed by the ENV HEALTH iurisdiction outside of San Joa uin Co. <br /> The commissary is located in b rAwxgti-A uZ> COu'%)IJ 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 `� �W&IL Date b 1,1'S 1 do jib <br /> 1868 E, Hazelton Avenue I Stockton, California 952051 T 209 468.34201 F .209 464-0138 1 www.sjgov.org/ohd <br />