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S A N sI OA Q U I N Environmental Health Department <br /> COUNTY <br /> r�Lq Greatness grows here. PICK 'N GO ICE CREAaf <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 f r2 � bY"V 1CeOe4-H'! Lic. Plate# <br /> Owner/Operator Name Ao'!,,,(_K <br /> Business Mailing Address-q,2�� <br /> City S f(X;%f(` 00 State G'� Zip `44ko 6i Bus. Ph.5/0-_7 Alt. Ph. <br /> 1, Aa1l-,L k TvE1 F S , 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 /> 3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> t <br /> Commissary Name P I C K fV g 0 J CXj?E7 9 r FA# <br /> Address 13 ) I�K�� AVS Bus. Phone aoct — c.\kAe-- /`7 L2�3 <br /> City S70 Cr 70/v- Zip C14- q 5 x. `Owner/Operator S'O�-7-,fV A/" S':aV C? <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal 0 3-compartment sink "�"Q Electrical hook-ups <br /> 0 Solid waste disposal 0 Food preparation Toilet and handwashing <br /> 0 Hot & Cold water for cleaning Store refrigerated food 0 Potable water <br /> 0 Store dry food/supplies �� Overnight parking 0 Vehicle wash <br /> I, Y— , 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 Date 3- <br /> 3. <br /> ---3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in S&Tpj County. The above food facility meets the <br /> commissary requirements in California Health & afety 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 />