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SAN l O A Q U I N Environmental Health Department <br /> COUNTY <br /> creorness crows here. PICK `N GO ICE CREAM <br /> 3412 E. MINER AVE. <br /> COMMISSARY AGREEMENT STOCKTON, CA 95205 <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 Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address T <br /> CityAij_kXq StateC_Zip %32a_Bus. Ph. 1510-4lo-- cT(C�LAIt. Ph. <br /> I, 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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR. <br /> Commissary Name P 1 C U7/ !q o C s C' �j jgCY� -FA# <br /> Address F-R (�a Nr Bus. Phone 0)-- 0 <br /> City 10z'W-r'j Zip Owner/Operator <br /> Check all appropriate services provided: <br /> p Wastewater disposal D 3-compartment sink 'EL Electrical hook-ups <br /> ® Solid waste disposal D Food preparation '-,Q Toilet and handwashing <br /> D Hot & Cold water for cleaning \q Store refrigerated food D Potable water <br /> D Store dry food/supplies ------43 Overnight parking D Vehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correct to the best of my k6owledge, 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 r(- Date10 <br /> =� <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 />