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SAN JOAOUIN Environmental Health Department <br /> -COUNT`( <br /> 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 C-j00n) 4#3nc_=-! i ee_ Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address <br /> � ' �Yratt��ej�JK ST— <br /> City�Y� d StateZip�'n_'4 Bus. Ph. 510-410— g(c*-Alt. Ph. <br /> t, 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 rj I Cnl b Cs � ��M FA# <br /> Address 3 Lt I L, may! ', rt;; V, Bus. Phone `��C�-- QA <br /> City Zip Owner/Operator <br /> Check all appropriate services provided: <br /> p Wastewater disposal 13 3-compartment sink 'IQ Electrical hook-ups <br /> p Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> [7 Hot & Coldwater for cleaning `-q Store refrigerated food L7 Potable water <br /> 0 Store dry food/supplies ___--43 Overnight parking O Vehicle wash <br /> I, , 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 � rr,r,�,, r��� � ; Date <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 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />