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Environmental Health Department <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 Bloom + Brew LLC Lie. Plate# 4WH3688 <br />Bus. Ph. (209) 346-2693 Alt. Ph. <br />Date <br />2. To be completed by COMMISSARY QWNER/OPERATOR <br />Date 03/2S/2C <br />DateREHS Signature <br />0 <br />E Electrical hook-ups <br />E Toilet and handwashing <br />El Potable water <br />El Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />_____________________FA#_______ <br />________Bus. Phone 209-338-3663 <br />Owner/OperatorWilliam Berkowitz <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />I Mark Luis Cruz <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 <br />SAN JOAQUIN <br />COUNTY <br />Greatness crows here. <br />Owner/Operator Name Rachele Viray <br />Business Mailing Address 1701 Maywood Ave <br />City Manteca State CA Zip95336 <br />I, h-AtPtfl-FZV , 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 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 penalties. <br />Signature_ <br />Commissary Name Ma* s Kitchen LLC <br />Address 1211 S. 7th Street <br />City Modesto/jp 95351 <br />Check all appropriate services provided: <br />EZ 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />El Overnight parking <br />, hereby state that the information I have provided is current, true and <br />/_____________________________________________________ ___________________ _ <br />3. To be completed by the ENVHEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in S-k\n', n 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 st^tusjjf their operating permit changes. <br />3/25/2^ zQ <br />•A ). . 4' -S ■