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Environmental Health Departmentfi r <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#60107*3 <br />Bus. Ph. (408) 896-5556 Alt. Ph. <br />Date <br />2. To be^bmpleted* by COMMISSARY OWNER/OPERATOR <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />REHS Signature Date <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 />E3 Electrical hook-ups <br />^3 Toilet and handwashing <br />y Potable water <br />V Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />_____________________FA# <br />_________Bus. Phone 209-338-3663 <br />Owner/Operator William Berkowitz <br />SAN JOAQUIN <br />------COUNTY------ <br />Greatness grows here. <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />Business Name Papa's Dumplings <br />Owner/Operator Name Xiaojiao Zhu <br />Business Mailing Address 1664 Dorothy Cmn <br />CityLivemore StateCA Zip94551 <br />I l|£LO , hereby state that the above information is current, true and correct to <br />the best of myVnowledge and aofee 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,^^pernYtTfolderjiiust notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. / <br />Signature <br />0 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />• <br />, 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 ownenshalLnotify the EHD immediately. <br /> Signature <br />Commissary Name Max's Kitchen LLC <br />Address1211 S. 7th Street <br />City Modesto zip95361 <br />Check all appropriate services provided: <br />Wastewater disposal <br />El Solid waste disposal <br />0 Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I Mark Luis Cruz