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Environmental Health Department <br />Lie. Plate #60107X3 <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />Date <br />EJ 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />O' Overnight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />------- ' . If the use of the <br />r must notify the EHD. Failure to notify this office may result in permit <br />_____<----- -------------------------Date -ryv I________ ' ' <br />gompietedby COMMISSARY QWNER/OPERATOR <br />Max's Kitchen LLC <br /> Electrical hook-ups <br />0 Toilet and handwashing <br />0 Potable water <br />0 Vehicle wash <br />hereby state that the information I have provided is current, true and <br />______________________FA# <br />_________Bus. Phone 209-338-3663 <br />Owner/Operator William Berkowitz <br />operator fails to comply with the conditions of this agreement, or if this agreement is mod.fied or cancelled, the <br />commissary owner shall notify the EHDjmmediately. <br />S ig n atu re a te—-------------------------- <br />TToTe completed by the ENyH^ThTjurisdiction 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 | Stockton. California 95205 | T 209 468-3420) F .209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />(' 1 ; ’■ ’ ■' <br />-/wins 1 pn(i lfy°ur commissary is located outside of San Joaquin County also complete section 3 <br />Complete sec»« <br />If. To becompleted by APPLICANT ' | <br />Business Nanie±aMS Du.mgli_n.qs--------- <br /> Owner/Operator Name. Xiaojiao Zhu----------- <br /> Business Mailing Address 1554Dorothy Cmn <br />r ♦, Livemore State CA Zip94551 Bus Ph (408) 896-5556 Alt. Ph. <br />. 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 Sar/Joaquyf County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discoj^mtied Jpe permit holcp <br />revocation and pe/talties. j <br />Signature \z t- <br />2. To bggi <br />Commissary Name <br />Aridrpss 1211 S.7th Street__________ <br /> City Modesto Zip 95351 <br />Check all appropriate services provided: <br />0 Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I Mark Luis Cruz